Deterra Bag

* indicates required field

*First Name

*Last Name

*Street Address 1

Street Address 2

Apartment #

*City

* State

*Zip

*County

*Email

Maximum request amount equals to 6 bags.

Small

Quantity of Small

Medium

Quantity of Medium

Large

Quantity of Large

* What is your reason for requesting a prescription disposal pouch?

No disposal location near me

Limited transportation

I do not feel comfortable disposing of medication at droff-off boxes near me

I saw an advertisement encouraging me to dispose of medication