SAP Registration

To register to receive product through the SAP, please complete the secure form providing information to confirm Health Canada’s authorization of your physician’s request and to provide billing information. Once the completed form has been submitted, your credit card will be charged, and product will be shipped. Confirmation of shipping with tracking information will be emailed to you. Please note product will not be shipped until all required information has been submitted. An invoice confirming payment will be sent to you by email for your records.

If you need assistance with the form please Contact Us.

Contact Information

Billing Address

Credit Card Information

I confirm that all above information is correct and authorize KYE Pharmaceuticals Inc. to bill my credit card for the amount of drug specified on my Letter of Authorization from the Special Access Unit at Health Canada. The amount charged will be $125.00 CDN per bottle of 100 capsules. I understand and agree that my information will be stored for future transactions on my account only if repeat requests are submitted and subsequent Letters of Authorization for additional product are received by KYE Pharmaceuticals.