New Resident Setup

New Resident Registration

This online intake collects the first-step resident, facility, representative, and medication safety details. The pharmacy will follow up by phone or in person with the residence for any remaining information.

Residence

Where the resident lives and where medication service will be coordinated.

Use the facility or home name staff would recognize. Room number is intentionally short because it is usually just a suite, room, or unit.

Facility / home name*

Room number

Resident

Legal identity details for the person being registered.

These fields should match Manitoba Health and pharmacy records where possible. PHIN is kept separate because it is shorter than a name or phone number.

Legal first name*

Legal last name*

Date of birth*

Sex*

PHIN*

Manitoba personal health identification number.

Resident phone, if applicable

Use this only if the resident has a direct phone.

Care and pharmacy contacts

Who currently supports prescriptions and medical follow-up.

Add the main family physician first. Use the add button for another regular physician, clinic, or prescriber contact. Current pharmacy details help us coordinate records.

Family physician

Physician name*

Clinic*

Phone*

Current pharmacy name*

Current pharmacy phone

Current pharmacy address

Financial representative

Leave blank if not applicable or not known yet.

This is the person we should contact for billing or account setup conversations. Payment details are not collected here.

This is me

Use this if the submitter is also the financial representative.

Name

Relationship

Primary phone

Secondary phone

Optional second number.

Address

Care representative

Leave blank if not applicable or not known yet.

This is the person we should contact for health-care decisions or medication questions when the resident cannot manage those conversations directly.

This is me

Use this if the submitter is also the care representative.

Same as financial representative

Most registrations use the same person for financial and care decisions.

Name

Relationship

Primary phone

Secondary phone

Optional second number.

Address

Submitter

Who is completing this online form today.

Use the contact information for the person we should call if anything in this submission needs clarification.

Who is submitting this?*

Submitter name*

Role / title

Submitter phone*

Submitter email*

Email is required

Health details

Medication safety details for the first setup conversation.

This is not the full clinical intake. Add the key allergy, diagnosis, and medication-safety information needed for pharmacy staff to start the setup call.

Allergies*

Current diagnoses / medical history*

Other medication notes

I am authorized to submit this resident setup information.

Tache Pharmacy will follow up by phone or in person for remaining registration details.

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