Service and Supply Request - PE

A service provider will be notified to perform the supply and pick up at your location within 10 business days.
Minimum delivery of two (2) items and a pick up of two (2) items are required to schedule a service.
Containers must be full before requesting a pickup.
Please keep a copy of the automated email receipt and the associated courier receipt on file at your pharmacy.

* Required information

PE Service and Supply Request

Service and Supply Request - Prince Edward Island

Pharmacy Information
Pharmacy Name*
HPSA ID*
Requester's Name*
Address*
Make sure the information below matches the pharmacy's shipping information.

Street Address City Province Postal Code
Phone Number*
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Requester's Information
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Requester's Name*
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Requester's Title*
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Pharmacist Licence #*
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Phone Number*
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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 returned medications have been placed in the medication return bin; liquid and cream medications are in their own vials.*
- Yes
- No
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2.) I confirm that there are no free liquid in the medication return container(s).*
- Yes
- No
2) I confirm that the bins are securely sealed.*
- Yes
- No
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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 three (3) items is required to schedule a service.
Sharp Case
Includes 75 sharp containers
Sharp Over-Packaging
1 flat return box
Liners for Over-Packaging
1 liner per flat return box
Medications Return Container
Includes 1 container and 1 lid
Total Number of Items (Calculated Field)
Minimum 3 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
Minimum 2 items is required. When this calculated field is correct, you will see submit button.
Comments or questions
Comments
This field is for validation purposes and should be left unchanged.

Service and Supply Request – PE

PE Service and Supply Request

Pharmacy Information

Requester's Information

Program Check-list

New Supply Order

Pick-up Request

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