Form for pharmacies

If your pharmacy is already enrolled in Celebrate life, Enter here::

A- Does your pharmacy belong to a chain that is already part of the program and do you want to register one or more new points of sale?

B - Does your pharmacy belong to a chain that is already part of the program and do you want to register one or more new points of sale?

Option A: Telephone

Option B: Internet Access

You must have the inventory available for the immediate delivery of the redemption to your patient
You will receive replacement of the redeemed product within a maximum of 15 days afterward by the distributor.

01. Physical or legal ID number under which the pharmacy is registered:

02. Name of the legal representative:

03. Legal Representative's ID:

04. Email of the legal representative:

05. Name of the person who will manage the program at the pharmacy:

06. Phone number of the person managing the program at the pharmacy:

07. Email of the legal representative:

08. Name of the person requesting to participate in the program.:

09. Email of the person requesting to participate in the program

10. Distributors you work with:

11. Preferred method for receiving reimbursement for your redemptions:

By Point of Sale

By Distribution Center

Pharmacy name	Address	Contact Name	Phone	Email	Province	Canton	District