Order Form - Tykess Pharmaceuticals

Contact Information

First and Last Name

Birthday

Email Address

Phone

Street Address

City

Zip/Postal Code

1-2 times 3-4 times 5 or more times

We may need to access your original prescription from your current pharmacy.

Pharmacy Name or Phone

Pharmacy Address/Intersection

Private or Employee Plan Provincial Plan No Insurance

By submitting your order you are consenting for Tykess to transfer your diabetes testing related prescriptions from your existing pharmacy to us.

After completing all the data, please submit the form on step two.