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

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

Personal Info

Sign in with Google







I identify as:





How much is your approximate household income? *not required

Why are we asking? This information will help us provide more resources to Canadians and will only be used anonymously. Your honesty and willingness to share your personal information are appreciated.


Activity Information

How much moderate to vigorous activity do you currently do each week (minutes)?


How much moderate to vigorous activity have you been doing each week for the past 6 months (minutes)?


Motivation Get More Active

My level of motivation to become more physcially active in the next 6 months is:


Improved physical health or chronic disease prevention
Improved mood/mental health
Weight Loss
Improved strength and increased muscle mass
Body image (how your body looks - beauty)
Rehabilitation from an injury
Improved posture



Barriers to Activity

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



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



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.


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



First Name:

Last Name: