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

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Let us know which clinic or location 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 easier it becomes to find your 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 prescriber’s name so that we can update the list.)

Consent and Signature



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