TPP Alberta | Prescription Pad Re-order Form - College of Physicians & Surgeons of Alberta

Note: TPP Alberta pads will continue to be delivered by Purolator in the event of Canada Post disruptions. However, please anticipate delivery delays due to a potential increase in the volume of deliveries through Purolator.

P.O. boxes and out-of-province addresses are not permitted for deliveries.

If your browser’s autofill is on, please review your form for accuracy before submitting. Consider disabling autofill to avoid unintended changes to your inputs.

Registrant information
Are you submitting this order for yourself?*
- Yes
- No
Your name*
First Last
Your email*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email
Name of practitioner*
First Last
Email of practitioner*
Enter Email Confirm Email
Practitioner regulatory body*
Regulatory body registration number*
Information printed on pad
Do you require a locum pad?*
Only your name and no addresses will be imprinted on TPP secure forms.
- Yes
- No
How many pads do you require?*
- 1
- 2
Clinic name printed on pad*
Clinic address printed on pad*
Street Address Address Line 2 City Province Postal Code
Clinic phone number printed on pad*
Shipping information
Shipping address*
ATTENTION: NO PO BOXES or OUT OF PROVINCE addresses allowed. Residential addresses will be verified by your regulatory body. A signature is required at time of delivery.

Street Address Address Line 2 City Province Postal Code
Shipping address*
ATTENTION: NO PO BOXES or OUT OF PROVINCE addresses allowed. Residential addresses will be verified by your regulatory body. A signature is required at time of delivery.

Same as clinic address

Street Address Address Line 2 City Province Postal Code
Shipping address contact phone number
If the shipping address is different from the clinic address, please enter a different phone number.
Special Instructions
Email
This field is for validation purposes and should be left unchanged.

Registrant information

Information printed on pad

Shipping information

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