Government of Ontario: Ministry of Health and Long-Term Care

Ontario Public Drug Programs
5700 Yonge Street, 3rd Floor
Toronto ON  M2M 4K5

Submission of Patient Evidence

Please send completed submission and/or any additional relevant information to the Ontario Public Drug Programs, Patient Evidence Submission, 5700 Yonge Street, 3rd Floor, Toronto ON  M2M 4K5, fax to 416 327-8123 or email to

Section I - Author Information

Telephone No. (incl. area code)

Section II - Conflict of Interest Declaration

Section III - Impact of the Disease/Condition

Confirmation of Authorship: