RxTGA - register

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REGISTER

Please complete the following form so that we may learn more about you and can tailor our program to meet the needs of all our participants. Once you have completed the form, and ‘click’ submit, you will gain access to all the opportunities Prescription to Get Active has to get you started and keep you active!

For further information, contact the Prescription to Get Active (RxTGA) Executive Director at 1 (866) 212-7552 or send an email to info@prescriptiontogetactive.com.

COMPLETE THIS FORM ONLY IF YOU HAVE RECEIVED A PRESCRIPTION Don’t have a prescription? Click here to Find a Prescriber

Barriers to Activity

Are there any barriers that have stopped you from participating in physical activity previously? *not required

Yes

If yes, please select all that apply: *not required

I have nowhere convenient to be physically activeI am limited financiallyI have an injury that limits my ability to be physically activeI don't have time based on the demands and prioirties in my lifeI don't have enough knowledge on how to be physically activeI am not motivated to be more physically activeI do not have support from family, friends etc. to become physically activeI have fears around becoming physically active

Other (please specify) - Not Required

Prescription

Let us know which clinic you received your prescription from.

Please note: The prescription is given either in the form of a tear-off-pad, a printout form or verbal instruction given to you during a virtual/phone consultation.

SEARCH TIPS

Click in the search window below then:

1. Begin typing the name of the clinic where you received your prescription. Use the scroll bar to view matches, then click on your clinic (the more letters typed the more specific the match)

2. Use the scroll bars to search through the alphabetized list of clinic locations to find a match.

My prescriber is not listed (Please provide the name of your clinic and prescribers name so that we may update the list.)

Consent and Signature

By checking this box, I consent to the collection of my personal information to help inform and improve RxTGA’s services and, to receive information about the program.

REQUIRED

By checking this box, I confirm that I have read and understand the RxTGA Terms of Service

REQUIRED

By checking this box, I agree that my electronic acceptance is the legal equivalent of my manual signature on this form.

First Name:

Last Name: