Restore Pharmaceuticals

Book Your Consultation

Complete this short intake form so our licensed prescriber can prepare for your consultation. This takes approximately 3 minutes. All information is kept strictly confidential and protected under PIPEDA.

Step 1 of 10 Patient Information

Step 1 of 10

Patient Information

This information is required for your licensed prescriber to verify your identity before prescribing.

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Date of Birth *

Please enter your date of birth.

Province of Residence *

Please select your province.

Email Address *

Please enter a valid email address.

Phone Number *

Please enter your phone number.

Ontario Health Card (OHIP) Number Recommended

Required for NAPRA identity verification. Leave blank if you do not have an OHIP card.

Are you 18 years of age or older? *

Yes No

Please confirm your age.

Please note: This service is currently available to patients 18 years of age and older. Please contact us directly at pharmacist@restorepharmaceuticals.com for assistance.

Step 2 of 10

Reason for Consultation

Select the condition you'd like to discuss with our licensed prescriber today.

What would you like treatment for? *

Muscle strain or sprain Joint pain or arthritis Back or neck pain Post-surgical pain Migraine or headache Other

Please select a condition.

Briefly describe your condition *

Please describe your condition.

Step 3 of 10

Symptom Details

Help our licensed prescriber understand the nature and severity of your symptoms.

How long have you had this condition? *

Less than 1 week 1–4 weeks 1–3 months More than 3 months

Please select a duration.

Rate your pain or discomfort *

1 — Minimal10 — Severe

5 / 10

Step 4 of 10

Symptom Screening

Please check any of the following that apply to you right now.

Do you have any of the following symptoms? *

Fever above 38°C Significant swelling or bruising Inability to bear weight or move the affected area Numbness or tingling Chest pain or shortness of breath None of the above

Please select at least one option.

Please note: One or more of your symptoms may require urgent in-person care. Our licensed prescriber will carefully review your answers and advise you on the safest next steps. If you are experiencing a medical emergency, please call 911 immediately.

Step 5 of 10

NSAID Safety Screening

Because our treatments contain diclofenac (a topical NSAID), Health Canada requires us to screen for certain conditions. Please answer honestly — your licensed prescriber will review all responses.

Have you ever been told you have kidney disease or reduced kidney function? *

Yes No Not Sure

Please provide details: (optional)

Have you ever been told you have liver disease? *

Yes No Not Sure

Please provide details: (optional)

Do you have a history of stomach ulcers, GI bleeding, or acid reflux disease? *

Yes No Not Sure

Please provide details: (optional)

Have you been diagnosed with heart disease, heart failure, or had a heart attack or stroke? *

Yes No Not Sure

Please provide details: (optional)

Are you currently taking any oral NSAIDs (e.g. ibuprofen, naproxen, Advil, Aleve, aspirin)? *

Yes No

Which NSAID(s) and dose? (optional)

Are you currently taking blood thinners (e.g. warfarin, Eliquis, Xarelto, aspirin 81mg)? *

Yes No

Which medication(s)? (optional)

Do you have any open wounds, broken skin, or active skin infections at the area where the cream or patch would be applied? *

Yes No

Please note: Topical diclofenac should not be applied to broken or infected skin. Our licensed prescriber will advise you on safe application during your consultation.

Step 6 of 10

Medical History

This information is used by our team to prescribe safely. Please answer all questions honestly.

Do you have any problems with your immune system, or are you taking medications that affect your immune system (e.g. high-dose steroids, chemotherapy)? *

Yes No

Please provide details: (optional)

Do you have any other significant medical conditions we should be aware of? Optional

Step 7 of 10

Allergies

Allergy information helps our pharmacist prepare your formulation safely.

Do you have any known drug allergies? *

Yes No

Please answer this question.

Please list your drug allergies: *

Do you have any other known allergies (food, environmental)? Optional

Step 8 of 10

Additional Health Information

The following questions help our team prescribe safely. All information is confidential.

Biological sex *

Male Female Prefer not to say

Please select an option.

Are you currently pregnant? *

Yes No

Are you currently breastfeeding? *

Yes No

Current medications Optional

Do you have any skin conditions (e.g. eczema, psoriasis, dermatitis) at or near the area where the cream or patch would be applied? *

Yes No

Please answer this question.

Please describe the condition: (optional)

STEP 9 OF 10

Previous Treatment Experience

Help our team understand what you've already tried so we can recommend the most effective compounded solution for your needs.

Have you previously tried any treatments for this pain condition? *

Yes No

Please answer this question.

Please describe what you tried and whether it helped: (optional)

Have you previously used any topical pain medications (creams, gels, or patches)? *

Yes No

Which product(s) and how did they work for you? (optional)

Anything else you'd like our licensed prescriber to know? Optional

Step 10 of 10

Informed Consent

Please read and agree to the following before submitting your consultation request.

By submitting this form, I confirm that:

1. Accuracy of information. All information I have provided is accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may affect the safety and appropriateness of any treatment prescribed.

2. Licensed prescriber review. I understand that a licensed Canadian prescriber will review my answers before any prescription is issued. This service does not provide automatic or instant prescriptions.

3. Privacy consent. I consent to Restore Pharmaceuticals collecting, storing, and using my personal health information for the purpose of this consultation, in accordance with the Personal Information Protection and Electronic Documents Act (PIPEDA) and applicable provincial privacy legislation.

4. Limitations of telemedicine. I understand that telemedicine has limitations and that my licensed prescriber may determine that an in-person assessment is required. I agree to follow up with an in-person healthcare provider if advised to do so.

5. Emergency care. I understand that this service does not replace emergency medical care. If I am experiencing a medical emergency, I will call 911 or go to the nearest emergency room immediately.

6. Right to withdraw. I understand that I may withdraw my consent at any time by contacting Restore Pharmaceuticals directly.

I have read and agree to the above terms and consent to this consultation.

You must agree to the consent terms to proceed.

I consent to my personal health information being collected, used, and stored by Restore Pharmaceuticals for the purpose of providing healthcare services, in accordance with PHIPA and PIPEDA. I understand my information will be stored securely in Canada and will not be shared with third parties without my consent, except as required by law.

You must agree to the privacy consent to proceed.

I confirm that I am currently located in a province where Restore Pharmaceuticals is licensed to operate, and I understand that this service is only available to eligible Canadian residents.

You must confirm your jurisdiction to proceed.

Something went wrong submitting your form. Please try again or contact us directly at pharmacist@restorepharmaceuticals.com.

Preparing your consultation…

Adding your recommended product and redirecting to checkout.

Your Personalized Recommendation

Based on your answers, our licensed prescriber has matched you with the formulation best suited to your condition. Your consultation request has also been submitted and a licensed prescriber will follow up within 1 business day.

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