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
Patient Advocacy Groups – Registration Form

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.

Section I

Office Address







Telephone No. (incl. area code)
Fax No. (incl. area code)

Primary Contact Person



Secondary Contact Person (if applicable)



Section II

Organization Represents

     

Primary Method of Contacting Members

        


Section III

  

Financial support or grants from government?

  

Potential conflicts of interest - financial support or grants
from pharmaceutical manufacturers?