New prescription Your informations Last Name First Name RAMQ Telephone Health informations Do you have any allergies? No Yes Are you pregnant? No Yes How many weeks? Do you breastfeed? No Yes Indicate the weight if the prescription is for a children under 12 years old. What other medications do you take? For what reason did the doctor prescribe you the medication? Photo of your prescription Join a copy of the prescription. You can take a picture with your phone. Notes Notes Get your medications Delivery I will pickup in person
New prescription Your informations Last Name First Name RAMQ Telephone Health informations Do you have any allergies? No Yes Are you pregnant? No Yes How many weeks? Do you breastfeed? No Yes Indicate the weight if the prescription is for a children under 12 years old. What other medications do you take? For what reason did the doctor prescribe you the medication? Photo of your prescription Join a copy of the prescription. You can take a picture with your phone. Notes Notes Get your medications Delivery I will pickup in person
