Prescription Transfer Form - Silver Scripts

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Submit Prescription

Prescription Transfer Authorization Form

Welcome to the Silver Scripts family! In order to get you started we’ll require additional information to create your pharmacy profile.

Email us

Team@SilverScripts.ca

Call us

1-844-909-7274

Note: You must reside in Canada to be eligible for the Silver Scripts services.

A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.

First Name

Last Name

Email Address

Contact Number

Health Card Number

Date of Birth

Gender

Home Address

Delivery Address (Optional)

Note: only fill this out if you would like to have your medications delivered to an alternate location. You can always change the delivery location at a later date.

1) Do you have any allergies? If yes please list them in the box below.

Yes No

List of Allergies

2) Do you have any medical conditions? If yes please list them in the box below.

Yes No

List of Medical Conditions

3) Who is your Family Doctor?

4) Previous Pharmacy details

Pharmacy Name

Phone Number

5) List your current medication (please separate medication names with a comma)

6) Would you like Silver Scripts to transfer your prescriptions now? If yes, please list your medications for transfer in the box below. (please separate medication names with a comma)

Yes Yes, same as above No

List of Prescriptions

Please upload two photos of the front and back of your card. Click on the “Browse” button to take a photo from your phone or upload existing images from your photo gallery.

Front Side

Back Side

Insurance Company

Client ID

Certificate Number

Group Number

Would you like to add a family member?

Yes No

Relationship

First Name

Last Name

Contact Number

Health Card Number

Date of Birth

Gender

Home Address

Delivery Address (Optional)

Medical Details

1) Do you have any allergies? If yes please list them in the box below.

Yes No

Family Member List of Allergies

2) Do you have any medical conditions? If yes please list them in the box below.

Yes No

List of Medical Conditions (please separate medications names with a comma)

3) Who is your Family Doctor?

4) Previous Pharmacy details

Pharmacy Name

Phone Number

5) List your current medication

6) Would you like Silver Scripts to transfer your prescriptions now? If yes, please list your medications for transfer in the box below.

Yes Yes, same as above No

Family Member List of Prescriptions

Insurance Details

Please upload two photos of the front and back of your card. Click on the “Browse” button to take a photo from your phone or upload existing images from your photo gallery.

Family Member Insurance Photo Front

Family Member Insurance Photo Back

Insurance Company

Client ID

Certificate Number

Group Number

Signature

Date

Consent

By clicking NEXT, I give consent to transfer prescriptions from my previous pharmacy to and to share medical and billing information with Silver Scripts for the provision of pharmacy services.

Before submitting your information, please review the summary below.

Licensed by

Accreditation 308397

Pharmacy Manager: Ludmilla Queiroz

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Call Us

1-844-909-7274

Email us

Team@SilverScripts.ca

Fax

1-844-909-7274

Silver Scripts Inc.

Pharmacy Hours of Operation
Mon - Fri | 9:30am - 5:30pm EST
5040 Mainway Unit 3D,
Burlington, ON, L7L 5Z1

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You must reside in Canada to be
eligible for the Silver Scripts services.