First Name*Last Name*Date of Birth*Alberta Health Card Number*Cell Phone Number*Email Address*Image of your drug coverage card(s) (If applicable)Please attach the picture of your drug coverage card(s) for billing.Delivery Date*Preferred Delivery Time*Please selectMon-Fri Morning 11 am to 3 pm (Cut off 9:45 am)Mon-Fri Evening 5 pm to 9 pm (Cut off 3:00 pm)Sat Morning only 10 am to 2 pm (Cut off 9:45 am)Sun Morning only 10 am to 2 pm (Cut off 9:45 am)Street Address*Address Line 2*City*Province*Postal Code*Delivery Notes*e.g. Leave at Joan at reception, place in mail box, call me when they are at the entrance.Terms of Service*By using our online pharmacy services you agree to our Terms of Use and Privacy Policy.SendThis field should be left blank