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Intake Form

Personal Information

General Information

Do you use tobacco products?
Do you regularly use any cannabis products?
Do consume any alcohol?
Do you take any nutritional / natural supplements?
Do you have any allergies?
Do you have any medical conditions or diseases?
Do you currently take any prescriptions?

Medical History

Have you been told you have any of the following :

Ischemic heart disease/ Previous Heart attack
Ischemic heart disease/ Previous Heart attack
Atrial Fibrillation
Diabetes
COPD
Asthma
Hypertension
CVA/ Stroke / TIA or mini-stroke
Thyroid Problems
Arthritis
Depression
Anxiety

Family History

OVER-THE-COUNTER (OTC) PRODUCT USE

Please select relevant over the counter medications that you currently take.

Thanks for your trust!

Contact Us

For any question or consultation, please fill in the form below

Thanks for submitting!

Our Pharmacy 

Address

9560 Markham Rd. Unit # 105 Markham. Ontario. L6E 0V1

Operation Hours

Monday & Friday
9:00 AM - 5:00 PM 

Tuesday - Thursday

9:00 AM - 7:00 PM

Saturday

9:00 AM - 2:00 PM

Sunday

Off 

Tel

289-554-9530

Fax

866-973-8510

Email

pharmacy@rxswift.net

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