Service and Supply Request - ON - Health Products Stewardship Association

A service provider will be notified to perform the supply and pickup at your location within 10 business days.
Minimum delivery of four (4) new items is required to schedule a service.
Containers and boxes must be full before requesting a pickup (no more than 23 kg per MRP container and 12 sharps containers per box).
Please keep a copy of the automated email receipt and the associated courier receipt on file at your pharmacy.

* Required information

Pharmacy Information
Pharmacy Name*
HPSA ID*
Address*
Make sure the information below matches the pharmacy's shipping information.

Street Address City Province Postal Code
Requester's Information
Requester's Name*
Requester's Title*
Pharmacist Licence #*
Phone Number*
Email*
Program Check-list
Please confirm the following. Should you have any doubt or answer NO to any of the questions below, please contact the HPSA Team at info@healthsteward.ca
1.) I confirm that only consumer returns of medications have been placed in the medication return containers.*
- Yes
- No
2.) I confirm that there are no free liquid in the medication return container(s).*
- Yes
- No
3.) I confirm that the lid on the medications return container has been securely sealed.*
- Yes
- No
4.) I confirm that the plastic liner within the Sharp Over-Packaging been tied off and the box sealed with tape.*
- Yes
- No
New Supply Order
Indicate the number of items to be delivered. A minimum delivery of four (4) items is required to schedule a service.
Sharp Kit
Includes: 24 sharp containers, 2 liners, 4 cytotoxic labels, 2 flat return boxes
Extra Sharp Over-Packaging
Includes: 2 flat return boxes & 2 liners only
Medications Return Container
Includes: 1 container, 1 lid, 1 liner & zipties
Total Number of Items (Calculated Field)
Minimum 4 items is required. When this calculated field is correct, you will see submit button.
Pick-up Request
Indicate the number of items to be picked-up.
Medications Return Container
Sharp Return Box
Approx. 12 sharp containers per box
Total Pick-up Calculated
Comments or questions
Please provide us any additional requests, comments or questions.
Additional requests, comments or questions
HPSA STAFF ONLY SECTION
HPSA use only (do not fill out)
Region/county: Service Provider: Date Sent: Received By:
Comments
This field is for validation purposes and should be left unchanged.

Service and Supply Request – ON

Pharmacy Information

Requester's Information

Program Check-list

New Supply Order

Pick-up Request

Comments or questions

HPSA STAFF ONLY SECTION