Prescription Drug Safety Supplies Request Form

Your Contact Information

Your name

Your email

Your phone number

Your address

City, State, and Zip Code

County in Idaho District 2
ClearwaterIdahoLatahLewisNez Perce

Preferred method of contact
PhoneE-Mail

Number of lock boxes requested
012More than 2

Number of drug deactivation pouches requested
012345More than 5

Number of Timer Caps requested
012345

To cut down on local shipping costs, we are offering pick up at our offices
Pick up in LewistonPick up in MoscowPick up in OrofinoPick up in GrangevillePick up in KamiahI am unable to pickup items, please mail them to me.

How did you hear about requesting prescription drug safety supplies?

Δ