RxTGA - register

REGISTER

Please complete the following form so that we may learn more about you and can tailor our program to meet the needs of all our participants. Once you have completed the form, and click 'submit', you will gain access to all the opportunities Prescription to Get Active has to get you started and keep you active!

For further information, contact the Prescription to Get Active (RxTGA) Executive Director at 1 (866) 212-7552 or send an email to info@prescriptiontogetactive.com.

COMPLETE THIS FORM ONLY IF YOU HAVE RECEIVED A PRESCRIPTION Don’t have a prescription? Click here to Find a Prescriber

Personal Info

First Name

Last Name

Phone

Postal Code

Create Password

Type Password again to confirm

Prescription

Let us know which clinic or location you received your prescription from.

Please note: The prescription is given either in the form of a tear-off-pad, a printout form or verbal instruction given to you during a virtual/phone consultation.

SEARCH TIPS

Click in the search window below then:

1. Begin typing the name of the clinic where you received your prescription. Use the scroll bar to view matches, then click on your clinic (the more letters typed the easier it becomes to find your match).

2. Use the scroll bars to search through the alphabetized list of clinic locations to find a match.

My prescriber is not listed (Please provide the name of your clinic and prescriber’s name so that we can update the list.)

Consent and Signature

Your anonymous input provides important information to help improve the quality of our program and services you receive. Your responses to registering and questions asked are completely confidential, and your name will not be attached to the responses you give.

By checking this box, I agree to the collection of my personal information to help inform and improve RxTGA’s services and, to receive information about the program.

REQUIRED

By checking this box, I confirm that I have read and understand the RxTGA Terms of Service

REQUIRED

By checking this box, I agree that my electronic acceptance is the legal equivalent of my manual signature on this form.

First Name:

Last Name: