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EIPH Partnership for Success Drug Safety Supply Order Request

Drug Safety Supply Order Request Form

Please fill out the order request form for the Drug Deactivation Pouch and/or Medication Lock Box.
(Eastern Idaho Public Health is NOT currently delivering these resources. Please plan to pick up requested resources at the EIPH office at 1250 Hollipark Drive, Idaho Falls [Monday-Friday 8am-12pm, 1pm-4:30pm].).
After you fill out the order request, we will contact you to go over details and availability before the order is completed. If you would like faster service and direct information on current stock please contact Eastern Idaho Public Health at 208-522-0310. The Drug Deactivation Pouch and Medication Lock Box is supported by Partnership for Success grant funded from CFDA 93.243.

*Required
1. Please enter your contact information:
County
This question requires a valid email address.
Preferred contact method? *This question is required.
What size(s) Deterra Pouch would you like to order? *This question is required.
2. Are you interested in a Medication Lock Box?
3. If you are interested in a Medication Lock Box, what size would you like?
4. How did you hear about Deterra Drug Deactivation Pouches and/or Medication Lock Boxes? 
5. Are you aware of any prescription drop off location(s) in your town?
6. How regularly do you clean out your medicine cabinet?
7. What type of medicine(s) do you plan to dispose of?
8. How comfortable are you in using Deterra Drug Deactivation Pouches?
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