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

Name*

First Last

Email*

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

Enter Email Confirm Email

Contact phone number*

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

Name of practitioner*

First Last

Email of practitioner*

Enter Email Confirm Email

Practitioner regulatory body*

Regulatory body registration number*

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*

Comments

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

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