Transcription of Narcotic Signing Request Form for Pharmacies - OCPInfo.com
1 Page 1 of 1 Version Number: Document Date: 10/6/2017 Narcotic Signing Request form for PharmaciesA Narcotic signer is a pharmacist designated by a pharmacy owner or designated manager to be authorized to order and sign the purchase order and receipt for narcotics received under the Controlled Drugs and Substances Act. Complete this form to add a new Narcotic signer or remove an existing Narcotic signer at an accredited community pharmacy or Drug Preparation Premises (DPP).SITE INFORMATION Community Pharmacy or Drug Preparation Premises (DPP)AToday s Date: Owner/Corporation Name: Site Name: Accreditation Number: Address: STREET ADDRESS CITY PROVINCE POSTAL CODE Narcotic SIGNERSB Pharmacist Name OCP Number ADD as a Narcotic Signer REMOVE as a Narcotic SignerEffective Date MM/DD/YYYY1) 2) 3) 4) 5) 6) 7) 8) AUTHORIZATION C I hereby authorize the addition and/or removal of Narcotic Signing privileges for the pharmacist(s) listed above.
2 _____ _____ _____ _____ Print Name OCP Number (if applicable)Role Signature Submit completed form by email to or fax to 416-847-8399, or mail to the attention of Pharmacy Applications & Renewals at 483 Huron St, Toronto, ON M5R 2R4 Please check the College s Public Register at for all Narcotic Signing updates.
