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New Member Form

Contract Concern

Select Form:

Materials Management
Nutrition & Food
Pharmacy

1. General Information

Submitted By (Name) Submitted By (Contact email) Reported by (Name) * Reported By (Contact email) *

Member Facility * Province * SSO/Health Authority *

2. Incident Information

Incident Date * Issue Type * Sample Product Available? * Reported to Supplier? *

Service Area *

Incident Details *

3. Contract Information

Contract Number

Contract Name

4. Supplier and Product Information

Supplier Name * Lot Number * Product Code *

Product Expiry Date * Product Description *

I would like to receive the copy of this form. (Materials Management)

1. General Information

Name Contact Email * Contact Phone *

Member Facility * Province * SSO/Health Authority *

2. Incident Information

Incident Date * Issue First Reported By * Reported to Supplier/Distributor? * Distributor Code * Supplier or Distributor issue was reported to (n/a if not applicable) *

Urgency *

Incident Details *

3. Contract Information

Contract Number *

Contract Name *

4. Product Information

Product Number (Manufacturer) * Supplier Name Lot Number *

Product Expiry Date * Product Description *

I would like to receive the copy of this form. (Nutrition & Food)

1. General Information

Submitted By (Name) Contact Email * Contact Phone * Facility *

Province * SSO/Health Authority *

2. Incident Information

Incident Date *

Issue First Reported By *

Reported to Supplier/Distributor? * Supplier or Distributor issue was reported to (n/a if not applicable) *

Risk Level

Incident Details *

3. Product Information

Generic Name * Strength * Format * Lot Number *

Size * Brand Name * Manufacturer * Product Expiry Date *

I would like to receive the copy of this form. (Pharmacy Form)

Member Success Form

Tech Support Form

New Supplier Form

Select Form:

Materials Management
Pharmacy

Contracting Support Form

Select Form:

Materials Management
Pharmacy

First Name * Last Name * City * Province/State * Country * Email * Phone Number *

Organization * I am an existing HealthPRO Canada supplier * I would like support regarding the following contract category *

Message *

I would like to receive the copy of this form. (Contract Support, Materials Management)

Notice of Product Change

1. Person Submitting Form

Name * Email *

Title Contact Phone *

2. Current Product Information

Supplier Name * Brand Name * Generic Name * Strength * Dosage Form *

Please include pictures of current product and new product, clearly labeled. Include as many as necessary. Accepted file types: PNG, JPEG, PDF

Packaging Format * Package Size (e.g. box of 10 vials) * Effective Date (First of Code Date) *

Date new product will be in general circulation *

Please provide the reason(s) for the changes

3. Product Code Changes

Manufacturer Product Code

Current

Future

McKesson Product Code

Current

Future

CPDN Product Code

Current

Future

Other Distributor Code

Current

Future

Distributor Name

4. Health Canada License Number Change

Drug Identification Number (DIN)

Current

Future

Natural Product Number (NPN)

Current

Future

Medical Device License (MDL)

Current

Future

5. GTIN and Barcode Change

GTIN on Unit of Purchase

Current

Future

GTIN on Unit of Use

Current

Future

GTIN on Case

Current

Future

Change in type of Barcode

Current

Future

6. Please indicate any changes to the format of your product

Current

Future

*For a product to be considered unit dose, it requires the following details for each individually wrapped tablet/capsule/liquid dose: generic name, strength, DIN, lot number, expiry date and name of manufacturer

7. Please describe any changes to the actual product appearance

Change in colour

Current

Future

Change in shape

Current

Future

Change to markings

Current

Future

Change to scoring on tablets

Current

Future

Change in dimensions

Current

Future

Change in weight of tablet/capsule/caplet/vial/ampoule

Current

Future

8. Package Size

Dimensions of outer package

Current

Future

Dimensions of inner package

Current

Future

Number of units per package

Current

Future

Change to case: weight

Current

Future

Change to case dimensions: Length/Width/Height

Current

Future

9. Other Changes

Change in concentration

Current

Future

Change in preservative content

Current

Future

Change in excipients or non-medicinal ingredients

Current

Future

Change in reconstitution instructions

Current

Future

Change in storage conditions

Current

Future

Change in stability information

Current

Future

Change in natural rubber latex content

Current

Future

Change to drug container (e.g. vial, ampoule)

Current

Future

Change in security features

Current

Future

Change to branding or other graphics

Current

Future

Other label changes

Current

Future

Other: please specify

Current

Future

I would like to receive the copy of this form. (Notice of Product Change)

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New Member Form

Contract Concern

Select Form:

1. General Information

2. Incident Information

3. Contract Information

4. Supplier and Product Information

1. General Information

2. Incident Information

3. Contract Information

4. Product Information

1. General Information

2. Incident Information

3. Product Information

Member Success Form

Select Form:

Tech Support Form

New Supplier Form

Select Form:

Contracting Support Form

Select Form:

Notice of Product Change

1. Person Submitting Form

2. Current Product Information

3. Product Code Changes

4. Health Canada License Number Change

5. GTIN and Barcode Change

6. Please indicate any changes to the format of your product

7. Please describe any changes to the actual product appearance

8. Package Size

9. Other Changes

Innovation Accelerator Program

Media Inquiry Form

Finance Inquiry Form

Marketing Inquiry Form

General Inquiry

Looking to connect? We are here to help.

Connect with Us

New Member Form

Contract Concern

Select Form:

1. General Information

2. Incident Information

3. Contract Information

4. Supplier and Product Information

1. General Information

2. Incident Information

3. Contract Information

4. Product Information

1. General Information

2. Incident Information

3. Product Information

Member Success Form

Select Form:

Tech Support Form

New Supplier Form

Select Form:

Contracting Support Form

Select Form:

Notice of Product Change

1. Person Submitting Form

2. Current Product Information

3. Product Code Changes

4. Health Canada License Number Change

5. GTIN and Barcode Change

6. Please indicate any changes to the format of your product

7. Please describe any changes to the actual product appearance

8. Package Size

9. Other Changes

Innovation Accelerator Program

Media Inquiry Form

Finance Inquiry Form

Marketing Inquiry Form

General Inquiry

Looking to connect?
We are here to help.