Collection Location Agreement

Please note that the HPSA Collection Location Agreement is not a substitute for a commercial waste disposal service agreement.

* Required information

Before you Begin
Is your pharmacy licensed by the College of Pharmacists and open for operations?*
- Yes
- No
Please submit the form once your pharmacy is licensed and open for operations.
Please select one of the following:*
To help us ensure compliance, please provide the name of the service provider who handles your commercial waste and the account number for your contract.**
Commercial waste is any waste generated by your pharmacy, such as medical sharps used for on-site immunizations (like COVID-19 or flu shots), recalled medications, samples or any expired drugs used in the pharmacy dispensary. It is your responsibility to arrange for proper disposal of those wastes through a commercial waste agreement, as they are not covered by the HPSA programs.
Is your pharmacy a retail community pharmacy?*
- Yes
- No
HPSA requires pharmacies to be open to the public as they will pose as collection sites.
Pharmacy Information
(As listed on College of Pharmacists)
Pharmacy Name*
Pharmacy Banner/Chain*

(e.g. Shoppers, Rexall, Independent)
College of Pharmacists Pharmacy Accreditation Number*
Contact Information
Pharmacy Manager Full Name*
First Last
Email Address*
Alternative Email
Phone Number*
Fax Number
Pharmacy Address
Pharmacy Address*
Street Address Unit/PO Box/RR# City Province Postal Code
Receiving Hours

Hours the service provider can deliver and pick-up HPSA containers
Terms & Conditions
Please review HPSA’s Collection Location Terms & Conditions.
- By checking this box, I agree to become a registered HPSA Collection Location and I confirm that I have read, understood, and agree to be bound by HPSA’s Collection Location Terms and Conditions.
Any information submitted on this form is for the sole purpose of HPSA in administering its programs. It will be protected and it will not be shared for any purposes outside of the administration of the services related to the programs.
- I agree to receive HPSA program updates
Name:*
Title:*
Date*
DD slash MM slash YYYY

(dd/mm/yyyy)
Consent*
- I agree to the privacy policy.
Please keep a copy of the email confirmation for your records. Make sure you check both your mailbox and your spam filter.
Comments
This field is for validation purposes and should be left unchanged.

Collection Location Agreement – MB

Before you Begin

Pharmacy Information

Contact Information

Pharmacy Address

Terms & Conditions

Our Offices