TPP Pad Reorder Form - College of Physicians & Surgeons of Alberta

To re-order a secure pad, please complete and submit the form below. Please note, P.O. boxes, home addresses, or out-of-province addresses are not permitted for deliveries.

Name*
First Last
Are you submitting this order for yourself?*
- Yes
- No
Name of Prescriber*
First Last
Email of Prescriber*
Enter Email Confirm Email
Email*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email
What regulatory body are you registered with?*
Regulatory body registration number*
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*
Clinic Address*
Address Line 1 Address Line 2 City Province Postal Code
Clinic Phone Number*
Shipping Address*
Same as clinic address

Address Line 1 Address Line 2 City Province Postal Code
Contact Phone Number
If different from clinic phone number
Special Instructions
Name
This field is for validation purposes and should be left unchanged.

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