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Deterra Bag

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First Name
Last Name
Street Address 1
Street Address 2
Apartment #
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Quantity of Small
Medium Medium
Quantity of Medium
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Quantity of Large

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* What is your reason for requesting a prescription disposal pouch? What is your reason for requesting a prescription disposal pouch?
No disposal location near me
Limited transportation
I do not feel comfortable disposing of medication at droff-off boxes near me
I saw an advertisement encouraging me to dispose of medication
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