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Submitted URL: https://lnktrk.canadianhealthcarenetwork.ca/ODI1LUxTUC01NDUAAAGTr82XzFB8H21iBF29JbiLa9crQvNPlCbED26EH-1qTB1uOhMMNxZg3kxOKV9Pdo0_2s3LHlY=
Effective URL: https://eiq.dragonforms.com/loading.do?mkt_tok=ODI1LUxTUC01NDUAAAGTr82XzI8dS0BoGJ_nxXbKADrZJ1IV3XgzL6ndv2bGnHDsLJ2aYmIwpXYsz...
Submission: On June 13 via api from CA — Scanned from CA
Effective URL: https://eiq.dragonforms.com/loading.do?mkt_tok=ODI1LUxTUC01NDUAAAGTr82XzI8dS0BoGJ_nxXbKADrZJ1IV3XgzL6ndv2bGnHDsLJ2aYmIwpXYsz...
Submission: On June 13 via api from CA — Scanned from CA
Form analysis 1 forms found in the DOM
POST saveNewSubscription.do;jsessionid=76FB2B6389366A61DA62D54C6106ED66
<form method="post" accept-charset="utf-8" action="saveNewSubscription.do;jsessionid=76FB2B6389366A61DA62D54C6106ED66" id="standardForm"><input type="hidden" name="14" id="14" value="1"><input type="hidden" id="dragonjsessionid"
name="dragonjsessionid" value="76FB2B6389366A61DA62D54C6106ED66"><input type="hidden" id="omedasite" name="omedasite" value="PT_QUAL"><input type="hidden" id="shippingaddresscountry" name="shippingaddresscountry" value="7">
<nav class="drgNav nav" style="display: none;"><select>
<option selected="selected" value="">Go to...</option>
</select></nav>
<div class="container contentbg bordertop borderleft borderright borderbottom">
<header class="row borderbottom headercontainer">
<div class="twelvecol">
<span class="logo"><img src="https://hostedcontent.dragonforms.com/hosted/images/dragon/12391/773.jpg" alt="PP+B Logo"></span>
<span class="cover"></span>
</div>
</header>
<header class="row">
<div class="twelvecol">
<span class="content0"></span>
</div>
</header>
<section class="row">
<div class="twelvecol">
<section class="content1">
<h2>New Subscription</h2>
<ul class="breadcrumb">
<li class="zoetic">
<div class="crumbitem current">Your Information</div>
</li>
<li class="">
<div class="crumbitem">Your Profile</div>
</li>
<li class="">
<div class="crumbitem">Confirmation</div>
</li>
</ul>
<input name="demo312880" type="hidden" value="web_qual" id="demo312880">
</section>
</div>
</section>
<section class="row">
<div class="twelvecol">
<section class="validation">
<ul></ul>
</section>
</div>
</section>
<section class="row">
<div class="sixcol">
<section class="content2">
<p id="p13" class="drg-element-type-standard-field drg-element-sub-type-fieldname-EMAILADDR addresslabel"><span class="questionlabel "><label for="id13">Email Address <font color="red">*</font></label> </span><input
class="drg-field-address-normal" name="demo312881" type="text" value="" id="id13" maxlength="50" size="50"></p>
<p id="p1" class="drg-element-type-standard-field drg-element-sub-type-fieldname-FIRSTNAME addresslabel"><span class="questionlabel "><label for="id1">First Name <font color="red">*</font></label> </span><input
class="drg-field-address-normal" name="demo312882" type="text" value="" id="id1" maxlength="40" size="40"></p>
<p id="p2" class="drg-element-type-standard-field drg-element-sub-type-fieldname-LASTNAME addresslabel"><span class="questionlabel "><label for="id2">Last Name <font color="red">*</font></label> </span><input
class="drg-field-address-normal" name="demo312883" type="text" value="" id="id2" maxlength="40" size="40"></p>
<p id="p10" class="drg-element-type-standard-field drg-element-sub-type-fieldname-TITLE addresslabel"><span class="questionlabel "><label for="id10">Job Title</label> </span><input class="drg-field-address-normal" name="demo312884"
type="text" value="" id="id10" maxlength="40" size="40"></p>
<p id="p3" class="drg-element-type-standard-field drg-element-sub-type-fieldname-COMPANY addresslabel"><span class="questionlabel "><label for="id3">Company Name</label> </span><input class="drg-field-address-normal" name="demo312885"
type="text" value="" id="id3" maxlength="40" size="40"></p>
<p id="p4" class="drg-element-type-standard-field drg-element-sub-type-fieldname-ADDRESS addresslabel"><span class="questionlabel "><label for="id4">Mailing Address 1 <font color="red">*</font></label> </span><input
class="drg-field-address-normal" name="demo312886" type="text" value="" id="id4" maxlength="255" size="255"></p>
<p id="p5" class="drg-element-type-standard-field drg-element-sub-type-fieldname-DEPARTMENT addresslabel"><span class="questionlabel "><label for="id5">Mailing Address 2</label> </span><input class="drg-field-address-normal"
name="demo312887" type="text" value="" id="id5" maxlength="255" size="255"></p>
<p id="p6" class="drg-element-type-standard-field drg-element-sub-type-fieldname-CITY addresslabel"><span class="questionlabel "><label for="id6">City <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo312888" type="text" value="" id="id6" maxlength="100" size="100"></p><span class="spanc7 drg-element-type-standard-field drg-element-sub-type-fieldname-COUNTRY">
<p id="p7" class="drg-element-type-standard-field drg-element-sub-type-fieldname-COUNTRY addresslabel"><span class="questionlabel "><label for="id7">Country <font color="red">*</font></label> </span><select name="demo312889"
id="id7">
<option value="">Select One</option>
<option value="81" [-selected312889_r81-]="">CANADA</option>
<option value="80" [-selected312889_r80-]="">UNITED STATES</option>
<option value="84" [-selected312889_r84-]="">AFGHANISTAN</option>
<option value="86" [-selected312889_r86-]="">ALBANIA</option>
<option value="87" [-selected312889_r87-]="">ALGERIA</option>
<option value="89" [-selected312889_r89-]="">ANDORRA</option>
<option value="90" [-selected312889_r90-]="">ANGOLA</option>
<option value="91" [-selected312889_r91-]="">ANGUILLA</option>
<option value="350" [-selected312889_r350-]="">ANTARCTICA</option>
<option value="92" [-selected312889_r92-]="">ANTIGUA</option>
<option value="93" [-selected312889_r93-]="">ARGENTINA</option>
<option value="94" [-selected312889_r94-]="">ARMENIA</option>
<option value="95" [-selected312889_r95-]="">ARUBA</option>
<option value="96" [-selected312889_r96-]="">ASCENSION IS</option>
<option value="97" [-selected312889_r97-]="">AUSTRALIA</option>
<option value="98" [-selected312889_r98-]="">AUSTRIA</option>
<option value="99" [-selected312889_r99-]="">AZERBAIJAN</option>
<option value="101" [-selected312889_r101-]="">BAHAMAS</option>
<option value="102" [-selected312889_r102-]="">BAHRAIN</option>
<option value="103" [-selected312889_r103-]="">BANGLADESH</option>
<option value="104" [-selected312889_r104-]="">BARBADOS</option>
<option value="106" [-selected312889_r106-]="">BELARUS</option>
<option value="108" [-selected312889_r108-]="">BELGIUM</option>
<option value="109" [-selected312889_r109-]="">BELIZE</option>
<option value="110" [-selected312889_r110-]="">BENIN</option>
<option value="111" [-selected312889_r111-]="">BERMUDA</option>
<option value="112" [-selected312889_r112-]="">BHUTAN</option>
<option value="113" [-selected312889_r113-]="">BOLIVIA</option>
<option value="115" [-selected312889_r115-]="">BOSNIA-HERZEGOVINA</option>
<option value="116" [-selected312889_r116-]="">BOTSWANA</option>
<option value="117" [-selected312889_r117-]="">BRAZIL</option>
<option value="351" [-selected312889_r351-]="">BRITISH INDIAN OCEAN TERRITORY</option>
<option value="118" [-selected312889_r118-]="">BRITISH VIRGIN IS</option>
<option value="120" [-selected312889_r120-]="">BRUNEI</option>
<option value="121" [-selected312889_r121-]="">BULGARIA</option>
<option value="122" [-selected312889_r122-]="">BURKINA FASO</option>
<option value="123" [-selected312889_r123-]="">BURUNDI</option>
<option value="124" [-selected312889_r124-]="">CAMBODIA</option>
<option value="125" [-selected312889_r125-]="">CAMEROON</option>
<option value="127" [-selected312889_r127-]="">CAPE VERDE ISLANDS</option>
<option value="128" [-selected312889_r128-]="">CAYMAN ISLANDS</option>
<option value="129" [-selected312889_r129-]="">CENTRAL AFRICAN REP</option>
<option value="130" [-selected312889_r130-]="">CHAD</option>
<option value="134" [-selected312889_r134-]="">CHILE</option>
<option value="135" [-selected312889_r135-]="">CHINA</option>
<option value="136" [-selected312889_r136-]="">COCO ISLAND</option>
<option value="137" [-selected312889_r137-]="">COLOMBIA</option>
<option value="138" [-selected312889_r138-]="">COMOROS</option>
<option value="139" [-selected312889_r139-]="">CONGO</option>
<option value="141" [-selected312889_r141-]="">COOK ISLANDS</option>
<option value="142" [-selected312889_r142-]="">COSTA RICA</option>
<option value="143" [-selected312889_r143-]="">CROATIA</option>
<option value="144" [-selected312889_r144-]="">CUBA</option>
<option value="145" [-selected312889_r145-]="">CYPRUS</option>
<option value="146" [-selected312889_r146-]="">CZECH REPUBLIC</option>
<option value="147" [-selected312889_r147-]="">DENMARK</option>
<option value="148" [-selected312889_r148-]="">DJIBOUTI</option>
<option value="149" [-selected312889_r149-]="">DOMINICA</option>
<option value="150" [-selected312889_r150-]="">DOMINICAN REPUBLIC</option>
<option value="151" [-selected312889_r151-]="">EAST TIMOR</option>
<option value="152" [-selected312889_r152-]="">ECUADOR</option>
<option value="153" [-selected312889_r153-]="">EGYPT</option>
<option value="154" [-selected312889_r154-]="">EL SALVADOR</option>
<option value="156" [-selected312889_r156-]="">ERITREA</option>
<option value="157" [-selected312889_r157-]="">ESTONIA</option>
<option value="158" [-selected312889_r158-]="">ETHIOPIA</option>
<option value="159" [-selected312889_r159-]="">FAEROE ISLANDS</option>
<option value="160" [-selected312889_r160-]="">FALKLAND ISLANDS</option>
<option value="161" [-selected312889_r161-]="">FIJI</option>
<option value="162" [-selected312889_r162-]="">FINLAND</option>
<option value="163" [-selected312889_r163-]="">FRANCE</option>
<option value="164" [-selected312889_r164-]="">FRENCH GUIANA</option>
<option value="165" [-selected312889_r165-]="">FRENCH POLYNESIA</option>
<option value="168" [-selected312889_r168-]="">GABON</option>
<option value="169" [-selected312889_r169-]="">GAMBIA</option>
<option value="171" [-selected312889_r171-]="">GEORGIA</option>
<option value="172" [-selected312889_r172-]="">GERMANY</option>
<option value="173" [-selected312889_r173-]="">GHANA</option>
<option value="174" [-selected312889_r174-]="">GIBRALTAR</option>
<option value="176" [-selected312889_r176-]="">GREECE</option>
<option value="177" [-selected312889_r177-]="">GREENLAND</option>
<option value="178" [-selected312889_r178-]="">GRENADA</option>
<option value="179" [-selected312889_r179-]="">GUADELOUPE</option>
<option value="180" [-selected312889_r180-]="">GUATEMALA</option>
<option value="181" [-selected312889_r181-]="">GUERNSEY</option>
<option value="182" [-selected312889_r182-]="">GUINEA</option>
<option value="183" [-selected312889_r183-]="">GUYANA</option>
<option value="184" [-selected312889_r184-]="">HAITI</option>
<option value="185" [-selected312889_r185-]="">HONDURAS</option>
<option value="186" [-selected312889_r186-]="">HONG KONG</option>
<option value="187" [-selected312889_r187-]="">HUNGARY</option>
<option value="188" [-selected312889_r188-]="">ICELAND</option>
<option value="189" [-selected312889_r189-]="">INDIA</option>
<option value="190" [-selected312889_r190-]="">INDONESIA</option>
<option value="191" [-selected312889_r191-]="">IRAN</option>
<option value="192" [-selected312889_r192-]="">IRAQ</option>
<option value="193" [-selected312889_r193-]="">IRELAND</option>
<option value="194" [-selected312889_r194-]="">ISLE OF MAN</option>
<option value="195" [-selected312889_r195-]="">ISRAEL</option>
<option value="196" [-selected312889_r196-]="">ITALY</option>
<option value="197" [-selected312889_r197-]="">IVORY COAST</option>
<option value="198" [-selected312889_r198-]="">JAMAICA</option>
<option value="199" [-selected312889_r199-]="">JAPAN</option>
<option value="200" [-selected312889_r200-]="">JORDAN</option>
<option value="201" [-selected312889_r201-]="">KAZAKHSTAN</option>
<option value="202" [-selected312889_r202-]="">KENYA</option>
<option value="204" [-selected312889_r204-]="">KIRIBATI</option>
<option value="206" [-selected312889_r206-]="">KUWAIT</option>
<option value="207" [-selected312889_r207-]="">KYRGYZSTAN</option>
<option value="208" [-selected312889_r208-]="">LAOS</option>
<option value="209" [-selected312889_r209-]="">LATVIA</option>
<option value="210" [-selected312889_r210-]="">LEBANON</option>
<option value="211" [-selected312889_r211-]="">LESOTHO</option>
<option value="212" [-selected312889_r212-]="">LIBERIA</option>
<option value="213" [-selected312889_r213-]="">LIBYA</option>
<option value="214" [-selected312889_r214-]="">LIECHTENSTEIN</option>
<option value="215" [-selected312889_r215-]="">LITHUANIA</option>
<option value="216" [-selected312889_r216-]="">LUXEMBOURG</option>
<option value="217" [-selected312889_r217-]="">MACAO</option>
<option value="218" [-selected312889_r218-]="">MACEDONIA</option>
<option value="219" [-selected312889_r219-]="">MADAGASCAR</option>
<option value="221" [-selected312889_r221-]="">MALAWI</option>
<option value="222" [-selected312889_r222-]="">MALAYSIA</option>
<option value="223" [-selected312889_r223-]="">MALDIVES</option>
<option value="224" [-selected312889_r224-]="">MALI</option>
<option value="225" [-selected312889_r225-]="">MALTA</option>
<option value="226" [-selected312889_r226-]="">MARSHALL ISLANDS</option>
<option value="227" [-selected312889_r227-]="">MARTINIQUE</option>
<option value="228" [-selected312889_r228-]="">MAURITANIA</option>
<option value="229" [-selected312889_r229-]="">MAURITIUS</option>
<option value="230" [-selected312889_r230-]="">MAYOTTE</option>
<option value="231" [-selected312889_r231-]="">MEXICO</option>
<option value="232" [-selected312889_r232-]="">MICRONESIA</option>
<option value="233" [-selected312889_r233-]="">MOLDOVA</option>
<option value="235" [-selected312889_r235-]="">MONACO</option>
<option value="236" [-selected312889_r236-]="">MONGOLIA</option>
<option value="237" [-selected312889_r237-]="">MONTENEGRO</option>
<option value="238" [-selected312889_r238-]="">MONTSERRAT</option>
<option value="239" [-selected312889_r239-]="">MOROCCO</option>
<option value="240" [-selected312889_r240-]="">MOZAMBIQUE</option>
<option value="241" [-selected312889_r241-]="">MYANMAR</option>
<option value="242" [-selected312889_r242-]="">NAMIBIA</option>
<option value="243" [-selected312889_r243-]="">NAURU</option>
<option value="244" [-selected312889_r244-]="">NEPAL</option>
<option value="245" [-selected312889_r245-]="">NETHERLAND ANTILLES</option>
<option value="246" [-selected312889_r246-]="">NETHERLANDS</option>
<option value="248" [-selected312889_r248-]="">NEW CALEDONIA</option>
<option value="249" [-selected312889_r249-]="">NEW GUINEA</option>
<option value="250" [-selected312889_r250-]="">NEW ZEALAND</option>
<option value="251" [-selected312889_r251-]="">NICARAGUA</option>
<option value="252" [-selected312889_r252-]="">NIGER</option>
<option value="253" [-selected312889_r253-]="">NIGERIA</option>
<option value="254" [-selected312889_r254-]="">NORTH KOREA</option>
<option value="256" [-selected312889_r256-]="">NORWAY</option>
<option value="257" [-selected312889_r257-]="">OMAN</option>
<option value="259" [-selected312889_r259-]="">PAKISTAN</option>
<option value="260" [-selected312889_r260-]="">PALAU</option>
<option value="261" [-selected312889_r261-]="">PALESTINE</option>
<option value="262" [-selected312889_r262-]="">PANAMA</option>
<option value="264" [-selected312889_r264-]="">PARAGUAY</option>
<option value="265" [-selected312889_r265-]="">PERU</option>
<option value="266" [-selected312889_r266-]="">PHILIPPINES</option>
<option value="268" [-selected312889_r268-]="">PITCAIRN IS</option>
<option value="269" [-selected312889_r269-]="">POLAND</option>
<option value="270" [-selected312889_r270-]="">PORTUGAL</option>
<option value="271" [-selected312889_r271-]="">QATAR</option>
<option value="272" [-selected312889_r272-]="">REUNION</option>
<option value="273" [-selected312889_r273-]="">ROMANIA</option>
<option value="274" [-selected312889_r274-]="">RUSSIA</option>
<option value="275" [-selected312889_r275-]="">RWANDA</option>
<option value="276" [-selected312889_r276-]="">SAN MARINO</option>
<option value="277" [-selected312889_r277-]="">SAO TOME E PRINCIPE</option>
<option value="279" [-selected312889_r279-]="">SAUDI ARABIA</option>
<option value="281" [-selected312889_r281-]="">SENEGAL</option>
<option value="282" [-selected312889_r282-]="">SERBIA</option>
<option value="283" [-selected312889_r283-]="">SEYCHELLES</option>
<option value="284" [-selected312889_r284-]="">SIERRA LEONE</option>
<option value="285" [-selected312889_r285-]="">SINGAPORE</option>
<option value="286" [-selected312889_r286-]="">SLOVAK REPUBLIC</option>
<option value="287" [-selected312889_r287-]="">SLOVENIA</option>
<option value="288" [-selected312889_r288-]="">SOLOMON ISLANDS</option>
<option value="289" [-selected312889_r289-]="">SOMALIA</option>
<option value="290" [-selected312889_r290-]="">SOUTH AFRICA</option>
<option value="291" [-selected312889_r291-]="">SOUTH KOREA</option>
<option value="292" [-selected312889_r292-]="">SPAIN</option>
<option value="293" [-selected312889_r293-]="">SRI LANKA</option>
<option value="294" [-selected312889_r294-]="">ST CROIX</option>
<option value="295" [-selected312889_r295-]="">ST KITTS</option>
<option value="296" [-selected312889_r296-]="">ST LUCIA</option>
<option value="298" [-selected312889_r298-]="">ST MARTIN</option>
<option value="299" [-selected312889_r299-]="">ST PIERRE</option>
<option value="300" [-selected312889_r300-]="">ST VINCENT</option>
<option value="301" [-selected312889_r301-]="">SUDAN</option>
<option value="302" [-selected312889_r302-]="">SURINAME</option>
<option value="303" [-selected312889_r303-]="">SWAZILAND</option>
<option value="304" [-selected312889_r304-]="">SWEDEN</option>
<option value="305" [-selected312889_r305-]="">SWITZERLAND</option>
<option value="306" [-selected312889_r306-]="">SYRIA</option>
<option value="308" [-selected312889_r308-]="">TAIWAN</option>
<option value="309" [-selected312889_r309-]="">TAJIKISTAN</option>
<option value="310" [-selected312889_r310-]="">TANZANIA</option>
<option value="312" [-selected312889_r312-]="">THAILAND</option>
<option value="314" [-selected312889_r314-]="">TOGO</option>
<option value="315" [-selected312889_r315-]="">TONGA</option>
<option value="316" [-selected312889_r316-]="">TRINIDAD AND TOBAGO</option>
<option value="317" [-selected312889_r317-]="">TUNISIA</option>
<option value="318" [-selected312889_r318-]="">TURKEY</option>
<option value="319" [-selected312889_r319-]="">TURKMENISTAN</option>
<option value="320" [-selected312889_r320-]="">TURKS ISLAND</option>
<option value="321" [-selected312889_r321-]="">TUVALU</option>
<option value="322" [-selected312889_r322-]="">UGANDA</option>
<option value="323" [-selected312889_r323-]="">UKRAINE</option>
<option value="324" [-selected312889_r324-]="">UNITED ARAB EMIRATES</option>
<option value="749" [-selected312889_r749-]="">UNITED KINGDOM</option>
<option value="325" [-selected312889_r325-]="">URUGUAY</option>
<option value="326" [-selected312889_r326-]="">UZBEKISTAN</option>
<option value="327" [-selected312889_r327-]="">VANUATU</option>
<option value="328" [-selected312889_r328-]="">VATICAN CITY</option>
<option value="329" [-selected312889_r329-]="">VENEZUELA</option>
<option value="330" [-selected312889_r330-]="">VIETNAM</option>
<option value="332" [-selected312889_r332-]="">WALLIS ISLAND</option>
<option value="333" [-selected312889_r333-]="">WESTERN SAHARA</option>
<option value="334" [-selected312889_r334-]="">WESTERN SAMOA</option>
<option value="335" [-selected312889_r335-]="">YEMEN</option>
<option value="336" [-selected312889_r336-]="">ZAIRE</option>
<option value="337" [-selected312889_r337-]="">ZAMBIA</option>
<option value="338" [-selected312889_r338-]="">ZIMBABWE</option>
</select></p>
</span>
<div id="disp312890" style="display:none;"><span class="spanc8 drg-element-type-standard-field drg-element-sub-type-fieldname-STATE">
<p id="p8" class="drg-element-type-standard-field drg-element-sub-type-fieldname-STATE addresslabel"><span class="questionlabel "><label for="id8">Province <font color="red">*</font></label> </span><select name="demo312890"
id="id8">
<option value="">Select One</option>
<option value="67" [-selected312890_r67-]="">ALBERTA</option>
<option value="69" [-selected312890_r69-]="">BRITISH COLUMBIA</option>
<option value="71" [-selected312890_r71-]="">MANITOBA</option>
<option value="73" [-selected312890_r73-]="">NEW BRUNSWICK</option>
<option value="75" [-selected312890_r75-]="">NEWFOUNDLAND AND LABRADOR</option>
<option value="77" [-selected312890_r77-]="">NORTHWEST TERRITORIES</option>
<option value="68" [-selected312890_r68-]="">NOVA SCOTIA</option>
<option value="79" [-selected312890_r79-]="">NUNAVUT</option>
<option value="70" [-selected312890_r70-]="">ONTARIO</option>
<option value="72" [-selected312890_r72-]="">PRINCE EDWARD ISLAND</option>
<option value="74" [-selected312890_r74-]="">QUEBEC</option>
<option value="76" [-selected312890_r76-]="">SASKATCHEWAN</option>
<option value="78" [-selected312890_r78-]="">YUKON TERRITORY</option>
</select></p>
</span></div>
<div id="disp312891" style="display:none;"><span class="spanc8 drg-element-type-standard-field drg-element-sub-type-fieldname-STATE">
<p id="p8" class="drg-element-type-standard-field drg-element-sub-type-fieldname-STATE addresslabel"><span class="questionlabel "><label for="id8">State <font color="red">*</font></label> </span><select name="demo312891" id="id8">
<option value="">Select One</option>
<option value="1" [-selected312891_r1-]="">ALABAMA</option>
<option value="2" [-selected312891_r2-]="">ALASKA</option>
<option value="3" [-selected312891_r3-]="">ARIZONA</option>
<option value="4" [-selected312891_r4-]="">ARKANSAS</option>
<option value="5" [-selected312891_r5-]="">CALIFORNIA</option>
<option value="6" [-selected312891_r6-]="">COLORADO</option>
<option value="7" [-selected312891_r7-]="">CONNECTICUT</option>
<option value="8" [-selected312891_r8-]="">DELAWARE</option>
<option value="9" [-selected312891_r9-]="">DISTRICT OF COLUMBIA</option>
<option value="10" [-selected312891_r10-]="">FLORIDA</option>
<option value="11" [-selected312891_r11-]="">GEORGIA</option>
<option value="12" [-selected312891_r12-]="">HAWAII</option>
<option value="13" [-selected312891_r13-]="">IDAHO</option>
<option value="14" [-selected312891_r14-]="">ILLINOIS</option>
<option value="15" [-selected312891_r15-]="">INDIANA</option>
<option value="16" [-selected312891_r16-]="">IOWA</option>
<option value="17" [-selected312891_r17-]="">KANSAS</option>
<option value="18" [-selected312891_r18-]="">KENTUCKY</option>
<option value="19" [-selected312891_r19-]="">LOUISIANA</option>
<option value="20" [-selected312891_r20-]="">MAINE</option>
<option value="21" [-selected312891_r21-]="">MARYLAND</option>
<option value="22" [-selected312891_r22-]="">MASSACHUSETTS</option>
<option value="23" [-selected312891_r23-]="">MICHIGAN</option>
<option value="24" [-selected312891_r24-]="">MINNESOTA</option>
<option value="25" [-selected312891_r25-]="">MISSISSIPPI</option>
<option value="26" [-selected312891_r26-]="">MISSOURI</option>
<option value="27" [-selected312891_r27-]="">MONTANA</option>
<option value="28" [-selected312891_r28-]="">NEBRASKA</option>
<option value="29" [-selected312891_r29-]="">NEVADA</option>
<option value="30" [-selected312891_r30-]="">NEW HAMPSHIRE</option>
<option value="31" [-selected312891_r31-]="">NEW JERSEY</option>
<option value="32" [-selected312891_r32-]="">NEW MEXICO</option>
<option value="33" [-selected312891_r33-]="">NEW YORK</option>
<option value="34" [-selected312891_r34-]="">NORTH CAROLINA</option>
<option value="35" [-selected312891_r35-]="">NORTH DAKOTA</option>
<option value="36" [-selected312891_r36-]="">OHIO</option>
<option value="37" [-selected312891_r37-]="">OKLAHOMA</option>
<option value="38" [-selected312891_r38-]="">OREGON</option>
<option value="39" [-selected312891_r39-]="">PENNSYLVANIA</option>
<option value="40" [-selected312891_r40-]="">RHODE ISLAND</option>
<option value="41" [-selected312891_r41-]="">SOUTH CAROLINA</option>
<option value="42" [-selected312891_r42-]="">SOUTH DAKOTA</option>
<option value="43" [-selected312891_r43-]="">TENNESSEE</option>
<option value="44" [-selected312891_r44-]="">TEXAS</option>
<option value="45" [-selected312891_r45-]="">UTAH</option>
<option value="46" [-selected312891_r46-]="">VERMONT</option>
<option value="47" [-selected312891_r47-]="">VIRGIN ISLANDS</option>
<option value="48" [-selected312891_r48-]="">VIRGINIA</option>
<option value="49" [-selected312891_r49-]="">WASHINGTON</option>
<option value="50" [-selected312891_r50-]="">WEST VIRGINIA</option>
<option value="51" [-selected312891_r51-]="">WISCONSIN</option>
<option value="52" [-selected312891_r52-]="">WYOMING</option>
</select></p>
</span></div>
<p id="p9" class="drg-element-type-standard-field drg-element-sub-type-fieldname-ZIP addresslabel"><span class="questionlabel "><label for="id9">Zip/Postal Code <font color="red">*</font></label> </span><input
class="drg-field-address-normal" name="demo312892" type="text" value="" id="id9" maxlength="9" size="9"></p>
<p id="p124" class="drg-element-type-standard-field drg-element-sub-type-fieldname-PHONE_MOBILE addresslabel"><span class="questionlabel "><label for="id124">Cell Phone Number</label> </span><input class="drg-field-address-normal"
name="demo312893" type="text" onkeyup="this.value = this.value.replace(/\D/g,'');" value="" id="id124" maxlength="20" size="20"></p><em><span style="font-size: smaller;">By submitting your mobile number, you agree to receive automated
text alerts from Ensemble IQ. Message & data rates may apply. You can opt-out anytime.</span></em>
</section>
</div>
<div class="sixcol last">
<section class="content3"><span class="spanc7 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p7" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id7">Which one of the following categories best describes your job function? <font color="red">*</font>
</label> </span><select name="demo312895" id="id7">
<option value="">Select...</option>
<option value="33">Association Pharmacist</option>
<option value="31">Consulting Pharmacist</option>
<option value="32">Government Pharmacist</option>
<option value="28">Hospital Pharmacist</option>
<option value="25">Retail Pharmacist/ Manager</option>
<option value="26">Retail Pharmacist/ Owner</option>
<option value="27">Retail Staff Pharmacist</option>
<option value="34">Retired Pharmacist</option>
<option value="29">University Pharmacist</option>
<option value="35">Other Pharmacist</option>
<optgroup class="select_response_subheader" label="---------------------------------"></optgroup>
<option value="37">Pharmacy Assistant</option>
<option value="36">Pharmacy Technician</option>
<option value="42">Pharmacy Student</option>
<optgroup class="select_response_subheader" label="---------------------------------"></optgroup>
<option value="40">Chain/Banner Executive Management</option>
<option value="5849">Pharmacy Manager (Non-Pharmacist)</option>
<option value="38">Manufacturer</option>
<option value="5850">Pharmacy Owner (Non-Pharmacist)</option>
<option value="41">Retail Staff (Non-Pharmacist)</option>
<option value="5793">Wholesaler</option>
<option value="45">Other</option>
</select></p>
</span>
<div id="disp312896" style="display:none;">
<p id="p912" class="drg-element-type-demographic drg-element-sub-type-type-3"><span class="questionlabel "><label for="id912">Other (please specify)</label> </span><input class="drg-field-normal" name="demo312896" type="text" value=""
id="id912" maxlength="15" size="15"></p>
</div>
<div id="disp312897" style="display:none;"><span class="spanc9 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p9" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id9">Are you a licensed pharmacist working in Canada?</label> </span><select name="demo312897" id="id9">
<option value="">Select...</option>
<option value="67">I am a licensed pharmacist</option>
<option value="68">I am not a licensed pharmacist</option>
</select></p>
</span></div>
<div id="disp312898" style="display:none;">
<p id="p12" class="drg-element-type-demographic drg-element-sub-type-type-3"><span class="questionlabel "><label for="id12">What is your primary license number?</label> </span><input class="drg-field-normal" name="demo312898" type="text"
value="" id="id12" maxlength="30" size="30"></p>
</div>
<div id="disp312899" style="display:none;"><span class="spanc11 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p11" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id11">Where was your license issued? </label> </span><select name="demo312899" id="id11">
<option value="">Select...</option>
<option value="150">Alberta</option>
<option value="149">British Columbia</option>
<option value="152">Manitoba</option>
<option value="155">New Brunswick</option>
<option value="157">Newfoundland and Labrador</option>
<option value="160">Northwest Territories</option>
<option value="156">Nova Scotia</option>
<option value="159">Nunavut</option>
<option value="153">Ontario</option>
<option value="158">Prince Edward Island</option>
<option value="154">Quebec</option>
<option value="151">Saskatchewan</option>
<option value="161">Yukon</option>
<option value="163">United States</option>
<option value="164">Foreign</option>
</select></p>
</span></div>
<div id="disp312900" style="display:none;">
<p id="p12" class="drg-element-type-demographic drg-element-sub-type-type-3"><span class="questionlabel "><label for="id12">What is your primary license number?</label> </span><input class="drg-field-normal" name="demo312900" type="text"
value="" id="id12" maxlength="30" size="30"></p>
</div>
<div id="disp312901" style="display:none;"><span class="spanc11 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p11" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id11">Where was your license issued?</label> </span><select name="demo312901" id="id11">
<option value="">Select...</option>
<option value="150">Alberta</option>
<option value="149">British Columbia</option>
<option value="152">Manitoba</option>
<option value="155">New Brunswick</option>
<option value="157">Newfoundland and Labrador</option>
<option value="160">Northwest Territories</option>
<option value="156">Nova Scotia</option>
<option value="159">Nunavut</option>
<option value="153">Ontario</option>
<option value="158">Prince Edward Island</option>
<option value="154">Quebec</option>
<option value="151">Saskatchewan</option>
<option value="161">Yukon</option>
<option value="163">United States</option>
<option value="164">Foreign</option>
</select></p>
</span></div>
<div id="disp312902" style="display:none;">
<p id="p10371" class="drg-element-type-demographic drg-element-sub-type-type-3"><span class="questionlabel "><label for="id10371">Please specify your expected year of graduation:</label> </span><input class="drg-field-normal"
name="demo312902" type="text" value="" id="id10371" maxlength="15" size="15"></p>
</div>
<div id="disp312903" style="display:none;"><span class="spanc11 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p11" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id11">Study Province</label> </span><select name="demo312903" id="id11">
<option value="">Select...</option>
<option value="150">Alberta</option>
<option value="149">British Columbia</option>
<option value="152">Manitoba</option>
<option value="155">New Brunswick</option>
<option value="157">Newfoundland and Labrador</option>
<option value="160">Northwest Territories</option>
<option value="156">Nova Scotia</option>
<option value="159">Nunavut</option>
<option value="153">Ontario</option>
<option value="158">Prince Edward Island</option>
<option value="154">Quebec</option>
<option value="151">Saskatchewan</option>
<option value="161">Yukon</option>
<option value="163">United States</option>
<option value="164">Foreign</option>
</select></p>
</span></div>
<div id="disp312904" style="display:none;"><span class="spanc6 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p6" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id6">What category best describes your primary place of work or practice?</label> </span><select name="demo312904"
id="id6">
<option value="">Select...</option>
<option value="9">Chain/Banner Head office</option>
<option value="5660">Chain Pharmacy (Corporately Owned)</option>
<option value="16">Educational Institution</option>
<option value="13">Hospital Pharmacy</option>
<option value="8">Independent pharmacy</option>
<option value="5661">Independently Owned Pharmacy Under Regional or National Banner</option>
<option value="19">National and Provincial Associations</option>
<option value="23">Others (Please Specify)</option>
</select></p>
</span></div>
<div id="disp312905" style="display:none;">
<p id="p911" class="drg-element-type-demographic drg-element-sub-type-type-3"><span class="questionlabel "><label for="id911">Other (please specify)</label> </span><input class="drg-field-normal" name="demo312905" type="text" value=""
id="id911" maxlength="15" size="15"></p>
</div>
<div id="disp312906" style="display:none;"><span class="spanc10 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p10" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id10">Please identify the pharmacy group you work for/operate under</label> </span><select name="demo312906"
id="id10">
<option value="">Select...</option>
<option value="69">A+P Canada</option>
<option value="70">Axis Pharmacy</option>
<option value="5808">Bay Pharmacies</option>
<option value="5662">Bayshore Specialty Rx</option>
<option value="71">Brunet/Clini Plus</option>
<option value="72">Calgary Co-op</option>
<option value="73">Costco Pharmacy</option>
<option value="74">Countercare/Counterwise</option>
<option value="75">Deli Pharmacies</option>
<option value="76">Familiprix</option>
<option value="77">Federated Co-op</option>
<option value="6170">Guardian</option>
<option value="6171">IDA</option>
<option value="78">Katz Group/ Drug Trading Company</option>
<option value="79">Lawton</option>
<option value="80">Loblaws (Drugstore Pharmacy/CENTRE Santu)</option>
<option value="81">London Drugs</option>
<option value="82">Lovell Drugs</option>
<option value="83">Main Drug Mart</option>
<option value="84">Ms Kesson Canada (FHCP/ARP)</option>
<option value="85">Medical Pharmacies Group</option>
<option value="86">Medicine Centre</option>
<option value="87">Medicine Shoppe</option>
<option value="5807">Metro</option>
<option value="7937">OnPharm</option>
<option value="88">Overwaitea Pharmacies</option>
<option value="89">Peoples Drug Mart</option>
<option value="90">Pharmachoice</option>
<option value="91">Pharmacy 1 Drug and Food</option>
<option value="5806">Pharmaprix</option>
<option value="92">Pharmasave Drugs</option>
<option value="93">PJC Jean Coutu</option>
<option value="94">Proxim/Proximed</option>
<option value="5811">Pure Integrative Pharmacy</option>
<option value="95">Remedy</option>
<option value="5810">Rexall</option>
<option value="96">Safeway Pharmacy</option>
<option value="6169">Save on Foods</option>
<option value="97">Shopper's Drug Mart</option>
<option value="5809">Sobeys Pharmacy</option>
<option value="98">Super Drug Mart</option>
<option value="99">Super Thrifty Drugs</option>
<option value="100">Uniprix/Clinique Santé</option>
<option value="101">Value Drug Mart</option>
<option value="102">Wal-Mart Pharmacy</option>
<option value="104">Other</option>
</select></p>
</span></div><input name="demo312907" type="hidden" value="5524" id="demo312907">
</section>
</div>
</section>
<section class="row">
<div class="twelvecol">
<section class="content4"><span class="spanc970 drg-element-type-demographic drg-element-sub-type-type-5">
<p id="p970" class="drg-element-type-demographic drg-element-sub-type-type-5"><span class="questionlabel ">Privacy Policy <font color="red">*</font> </span></p>
<ul>
<li class="licr970_6008 lier312908_6008 "><input name="demo312908" type="checkbox" value="6008" id="id970_6008"><span class="checkboxlabel"><label for="id970_6008">I accept Ensemble IQ
<a href="https://ensembleiq.com/terms-and-conditions">Terms and Conditions</a> and acknowledge that my information will be used in accordance with Ensemble IQ
<a href="https://ensembleiq.com/privacy-policy">Privacy Policy</a>.</label></span></li>
</ul>
</span>
<div id="disp312909" style="display:none;"><span class="spanc10263 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p10263" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "> </span></p>
<ul>
<li class="licr10263_9971 lier312909_9971 "><input name="demo312909" type="radio" value="9971" id="id10263_9971"><span class="radiolabel"><label for="id10263_9971">Do not sell my personal information.</label></span></li>
</ul>
</span></div><br>
<hr><br>
<div id="disp312911" style="display:none;"><span class="spanc112 drg-element-type-standard-field drg-element-sub-type-fieldname-REQUESTED_VERSION">
<p id="p112" class="drg-element-type-standard-field drg-element-sub-type-fieldname-REQUESTED_VERSION"><span class="questionlabel "><strong>Please choose your subscription: </strong>
<font color="red">*</font>
</span></p>
<ul>
<li class="licr112_998 lier312911_998 "><input name="demo312911" type="radio" value="998" id="id112_998" [-checked312911_r998-]=""><span class="radiolabel"><label for="id112_998">Print</label></span></li>
<li class="licr112_999 lier312911_999 "><input name="demo312911" type="radio" value="999" id="id112_999" [-checked312911_r999-]=""><span class="radiolabel"><label for="id112_999">Digital</label></span></li>
<li class="licr112_1000 lier312911_1000 "><input name="demo312911" type="radio" value="1000" id="id112_1000" [-checked312911_r1000-]=""><span class="radiolabel"><label for="id112_1000">Print + Digital</label></span></li>
</ul>
</span></div>
<div id="disp312912" style="display:none;"><input name="opt312912" type="hidden" value="1" id="optd186"></div>
<div id="disp312913" style="display:none;"><input name="opt312913" type="hidden" value="1" id="optd2"></div>
<div id="disp312914" style="display:none;"><input name="opt312914" type="hidden" value="1" id="optp260"></div>
<div id="disp312915" style="display:none;"><input name="opt312915" type="hidden" value="1" id="optd273"></div>
<div id="disp312916" style="display:none;"><input name="opt312916" type="hidden" value="1" id="optd274"></div>
<div id="disp312917" style="display:none;"><input name="opt312917" type="hidden" value="1" id="optd275"></div>
<div id="disp312918" style="display:none;"><input name="opt312918" type="hidden" value="1" id="optd282"></div>
<div id="disp312919" style="display:none;"><input name="opt312919" type="hidden" value="1" id="optd281"></div>
</section>
</div>
</section>
<section class="row">
<div class="twelvecol last">
<section class="submit">
<input type="submit" value="Submit" id="custombtn">
</section>
</div>
</section>
</div>
<footer class="row footer">
<div class="twelvecol">
<section class="footerText">
<p style=""><span style="font-size: larger;"><span style="font-size: smaller;"><span style="font-size: larger;">Your name and address information including email address will be used to correspond with you regarding your subscription, and to
send you newsletters and other relevant information.</span></span></span></p>
<p style=""><span style="font-size: larger;"><span style="font-size: smaller;"><span style="font-size: larger;">Please view our full
<a href="https://ensembleiq.com/privacy-policy"><span style="mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin;"><font color="#0000ff">Privacy Policy</font></span></a> for more details.</span></span></span></p><br>
<span style="font-size: larger;">To contact customer care, please email <a href="mailto:pharmacypractice@canadianhealthcarenetwork.ca">pharmacypractice@canadianhealthcarenetwork.ca</a> or call 1-877-687-7321.</span><br>
</section>
</div>
</footer>
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NEW SUBSCRIPTION * Your Information * Your Profile * Confirmation Email Address * First Name * Last Name * Job Title Company Name Mailing Address 1 * Mailing Address 2 City * Country * Select OneCANADAUNITED STATESAFGHANISTANALBANIAALGERIAANDORRAANGOLAANGUILLAANTARCTICAANTIGUAARGENTINAARMENIAARUBAASCENSION ISAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIA-HERZEGOVINABOTSWANABRAZILBRITISH INDIAN OCEAN TERRITORYBRITISH VIRGIN ISBRUNEIBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCAPE VERDE ISLANDSCAYMAN ISLANDSCENTRAL AFRICAN REPCHADCHILECHINACOCO ISLANDCOLOMBIACOMOROSCONGOCOOK ISLANDSCOSTA RICACROATIACUBACYPRUSCZECH REPUBLICDENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICEAST TIMORECUADOREGYPTEL SALVADORERITREAESTONIAETHIOPIAFAEROE ISLANDSFALKLAND ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUATEMALAGUERNSEYGUINEAGUYANAHAITIHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRANIRAQIRELANDISLE OF MANISRAELITALYIVORY COASTJAMAICAJAPANJORDANKAZAKHSTANKENYAKIRIBATIKUWAITKYRGYZSTANLAOSLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIAMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIAMOLDOVAMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLAND ANTILLESNETHERLANDSNEW CALEDONIANEW GUINEANEW ZEALANDNICARAGUANIGERNIGERIANORTH KOREANORWAYOMANPAKISTANPALAUPALESTINEPANAMAPARAGUAYPERUPHILIPPINESPITCAIRN ISPOLANDPORTUGALQATARREUNIONROMANIARUSSIARWANDASAN MARINOSAO TOME E PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESLOVAK REPUBLICSLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH KOREASPAINSRI LANKAST CROIXST KITTSST LUCIAST MARTINST PIERREST VINCENTSUDANSURINAMESWAZILANDSWEDENSWITZERLANDSYRIATAIWANTAJIKISTANTANZANIATHAILANDTOGOTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS ISLANDTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMURUGUAYUZBEKISTANVANUATUVATICAN CITYVENEZUELAVIETNAMWALLIS ISLANDWESTERN SAHARAWESTERN SAMOAYEMENZAIREZAMBIAZIMBABWE Province * Select OneALBERTABRITISH COLUMBIAMANITOBANEW BRUNSWICKNEWFOUNDLAND AND LABRADORNORTHWEST TERRITORIESNOVA SCOTIANUNAVUTONTARIOPRINCE EDWARD ISLANDQUEBECSASKATCHEWANYUKON TERRITORY State * Select OneALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING Zip/Postal Code * Cell Phone Number By submitting your mobile number, you agree to receive automated text alerts from Ensemble IQ. 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