MANITOBA PRESCRIBING PRACTICES PROGRAM (M3P)
It is my intention to prescribe designated drug(s) and I will require the initial issues of multiple
prescriptions. In making this application I recognize that:
I am required to keep secure and be accountable for every prescription issued under my name.
Loss or theft of pads will be reported promptly both verbally and in writing to the Manitoba
Prescribing Practices Program (M3P).
Designated drugs can be prescribed only with the use of the multiple prescription and I have
the responsibility to re-order prescriptions.
The multiple prescription must be completed accurately, completely, and legibly to be valid.
Invalid prescriptions will not be filled.
Physician Name (Please Print)
Full Office Mailing Address
where the pads will be mailed
(This address should be your Primary
Practice Location in our database)
Application Date
Signature of Physician
Registration #
Registration Start Date
FOR OFFICE USE ONLY
Validation by Registering Body
(Authorized Signature)
Date Authorized
Input Date
Date sent to CPhM
Return application via:
EMAIL CPSMM3P@cpsm.mb.ca or FAX TO (204) 774-0750
Upon approval, this application information will be forwarded to the Manitoba Prescribing Practices Program
(M3P).
REVISION: August 2021
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signature
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