Emergency Form

Which pharmacy should receive it?

Search by pharmacy name, name and city (for example “Cedar, Surrey”), or a phone or fax number.

Fill in the documentation

Everything here prints on the page.

Prescriber name

Prescriber ID4 to 10 letters or numbers

Patient name

Pharmacist (if known)

Brief description of the emergency situation

Telehealth consultation, prescription faxed In-person consultation, prescription faxed Prescription extended for continuity of care Appointment conflicted with work, prescription faxed

Next appointment (optional)

Time

Description

Date

Signature date

Check the page

This is the page the pharmacy will receive.

Emergency Fax Controlled Prescription Program Form Documentation

The prescriber asks the pharmacy below to accept a faxed Controlled Prescription Program form for this patient. The form must be faxed to and received by the pharmacy before it dispenses.

Prescriber
Prescriber ID
Pharmacy
Brief description of the emergency situation
Signature date
Prescriber’s signature: Electronically signed

Patient name
Pharmacist
Date

I am the prescriber named above and I approve this page.

Your form is ready.

Fax it together with the Controlled Prescription Program form to the same number.