REQUEST TO DESTROY DRUGS COVERED BY THE …

1 REQUEST TO DESTROY DRUGS COVERED BY THE controlled DRUGS AND SUBSTANCES ACT TO: National compliance section office of controlled Substances Health Canada 123 Slater Street AL3502B Ottawa, Ontario K1A 0K9 Phone#: (613) 954-1541 Fax #: (613) 957-0110 Email: Pharmacy Name: Street Address Box (if applicable) City/Town Province Postal Code ( ) ( ) Pharmacy Address.

2 Phone Number Fax Number Name Registration # FROM: Pharmacist-in-Charge: Signature Date of REQUEST Quantity & Form drug Name and Strength Expiry Date Lot Number Signature of Pharmacist-in-Charge Signature of Witness Date of Destruction Date Witnessed