Deterra Bag

* indicates required field

*First Name

*Last Name

*Street Address 1

Street Address 2

Apartment #

*City

* State

*Zip

*County

*Email

The max that someone can order total is 400. There is going to be an additional text field that communicates that fine print.

Small

Quantity of Small

Medium

Quantity of Medium

Large

Quantity of Large

* 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