TPP Alberta | Unused Prescription Pad Return Form - College of Physicians & Surgeons of Alberta

Registrant information

Are you returning pad(s) on behalf of someone else?*

Your name*

First Last

Your email*

This is the email address we will send a submission confirmation notification to.

Enter Email Confirm Email

Contact phone number*

Name of practitioner*

First Last

Email of practitioner*

Enter Email Confirm Email

Practitioner regulatory body*

Regulatory body registration number*

Hidden

Regulatory body registration number*

(Hidden to keep old data)

Reason for return*

Number of pads being returned*

Please list the start and end tracking numbers for each pad being returned

Please strike a line through each unused form to mark it as void*

How are the pads being returned?*

If pads are being returned by courier, please provide the company name and tracking number

Date returned (should be typed in the format mm/dd/yyyy, as in 03/15/2023)*

Comments

Email

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