Ontario Public Drug Programs 5700 Yonge Street, 3rd Floor Toronto ON M2M 4K5
Please send completed Registration Form 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 PatientSubmission.OPDP@ontario.ca.
Name of Organization
Unit No. Street No. Street Name PO Box City/Town Province Postal Code
Organization Web Site
Last Name First Name Middle Name
Patients Caregivers Other (Specify)
Membership Numbers
Phone Mail E-Mail Other (Specify)
Mission Statement or Purpose of Organization
Non-Profit Registered Charitable Organization
No Yes
No Yes (Specify Name of Pharmaceutical Manufacturer(s))