CCTH Form #601 - Prescription Renewal Request

CC TeleHealth is NOT a primary healthcare provider, and its services are intended to be complementary to, and not replace, those provided by your general practitioner. Further, CC TeleHealth only provides services that are Covid-19 and Post Covid-19 oriented, that are not covered by provincial health care plans, and charges a fee for its services. You should always first contact your primary health care provider for all "government-insured" health care services.

Warning: If this form is filled out on a cell phone, we may not receive your submission. For the best results, please complete it on a desktop or laptop computer

Prescription Renewal Request Form

Thank you for showing an interest in our services.
Please refer to our website to sign up for an appointment.

Name of practitioner at your last appointment

Date of last appointment

Since it has been longer than 6 months, please click on this link and complete the following intake form instead.

I understand that I am requesting a prescription renewal appointment. ($179)

I understand that I am responsible for the additional cost of the prescribed medications and nutraceuticals.

I understand that payment must be made before booking the appointment.

Once payment is received, you will be contacted within 24 hours on weekdays to schedule your appointment. (Payment links are at the bottom of this page)

Date

First Name

Last Name

What province do you live in?

Address 1

Address 2

City

Postal Code

Email Address

Phone Number

Date of Birth

Please call the pharmacy to confirm all refills have been filled before proceeding.

Please list all health history changes since your last appointment at CC TeleHealth.

Please list all medications that have changed since your last appointment at CC TeleHealth.

Please click on one of the following options to indicate why a prescription renewal is being requested.

I am taking a prophylactic dose and am out of refills.

I came into close contact with someone that had Covid, and so I took the prescription as a precautionary measure and would like to renew my prescription.

I would like to discuss the possibility of adding another medication to my current prevention prescription.

My health history has changed since my last appointment and therefore prescriptions may need to be adjusted.

Variant protocols have changed and I would like my prescription revisited.

I would like a renewal as my current prescription is about to expire.

It has been longer than 6 months since my last appointment.

Other

If an option from above does not apply, please indicate why a prescription renewal is being requested.

Confirm Information Provided

Date Confirmed Information Provided

I confirm that the above information is true and accurate.

Signatory is:

Client Primary Care Giver

Payment

Please follow the link for payment.

Prescription Renewal $179 - Pay Here

I understand that payment must be made prior to booking the appointment. Please select the appropriate link above. You will also find payment links in the confirmation email that you will receive upon submitting this form. (Please monitor your spam or junk folder for an email that provides more information about our process including the payment links.)

Kind regards,
CC TeleHealth

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