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

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

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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
Name
This field is for validation purposes and should be left unchanged.

Registrant information

Information printed on pad

Shipping information

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