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By submitting this form, you acknowledge that the information provided is accurate and complete to the best of your knowledge. This form is intended solely for the purpose of booking an appointment for a medication-related consultation and does not replace a direct consultation with a pharmacist or physician. Please note that any medication request or recommendation will only be fulfilled after a full consultation, which may include a review of your medical history, current medications, and any necessary lab results. All personal health information provided in this form will be handled in accordance with the Personal Information Protection Act (PIPA) of BC and the College of Pharmacists of BC’s standards on patient confidentiality. This form is not for emergency use. If you are experiencing a medical emergency, please contact 911 or your nearest healthcare facility. The pharmacy reserves the right to decline or reschedule appointments if necessary. You may also need to adapt this further based on the specific policies of your pharmacy or the scope of services you offer. Let me know if you need any additional modifications!
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