Ontario pharmacist pre-visit intake

Minor ailments assessment.

Choose one Ontario minor ailment and the form will show follow-up questions tailored to that concern. The pharmacist makes the clinical decision after professional review.

About 4–6 minutes

Pick the condition first.

After you choose the minor ailment, the next section automatically changes to the questions most relevant to that concern.

18+ onlyOntario focusedPharmacist review

Privacy & consent

Your answers are collected to coordinate and support pharmacist review. Full health answers stay in the secure backend; notification emails contain only a reference number and care area. Read the privacy notice.

About youBasic information needed to coordinate care.

Full nameEmailPhone optionalAge range

Are you currently located in Ontario?

A regulated professional must confirm your identity and location before providing virtual care.

Choose the minor ailmentSelect one concern. You can read definitions on the minor ailments page.

Which concern would you like the pharmacist to review?

Questions for this concernThe questions below change based on the minor ailment you selected.

Choose a minor ailment above to continue.

Overall, how long have the symptoms been present?How are the symptoms changing?Have you already tried self-care or a non-prescription product for this concern?

Medical history, medicines & allergiesOnly provide details when they apply.

Do you have any ongoing medical conditions or significant past surgeries?Do you take any prescription medicines regularly?Do you have any medication allergies or previous serious medication reactions?Have you been admitted to hospital or visited an emergency department in the last 12 months?Do you have a regular family doctor, nurse practitioner, or other primary-care provider?

Final notes & consentReview these acknowledgements before submitting.

Anything else the pharmacist should know? optionalI confirm I am 18 years of age or older and I am submitting this information for myself.I understand what information is being collected and why, and I consent to RefyllRx using it to coordinate and support pharmacist review. I may choose not to submit this form.I understand that my identity must be confirmed before virtual care is provided.I understand that my current location must be confirmed before virtual care is provided.I understand this form is not monitored for emergencies and I should call 911 or seek urgent care for severe or rapidly worsening symptoms.

Submitting this form does not create a clinician-patient relationship and does not guarantee treatment or a prescription.