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Medication Disposal Bag Request Form
Please fill out the form below to request Deterra Medication Disposal bags.
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* Indicates required question
First and Last Name
*
Your answer
Email
*
Your answer
How did you find this request form?
*
A code on a Deterra Bag that I used
A code on a Deterra Bag that belonged to someone else
Google Search
LEAF's Web site
A Facebook Post
Other:
How many bags do you need (maximum 3 per request)
*
Each pouch can deactivate: 45 Pills/Films OR 6 Patches OR 6 oz/180 ml of Liquids/Creams
Min
1
2
3
Max
How would you like to receive the bags?
*
Pickup
Delivery by Mail
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