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Service and Supply Request – ON
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
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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
0
1
2
Extra Sharp Over-Packaging
Includes: 2 flat return boxes & 2 liners only
0
1
2
Medications Return Container
Includes: 1 container, 1 lid, 1 liner & zipties
0
1
2
3
4
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.
Happy World Pharmacists Day 2020! Thank you for your support!