DisposeRx Packets Request Form

DisposeRx Packets

Please complete this form to receive DisposeRx packet(s). DisposeRx is an at-home site-of-use disposal solution for medications. To learn more, visit DisposeRx.com. Please allow 1-2 weeks for arrival of the packets. Packets will only be provided to those in South Dakota. Questions? Please contact the Resource Hotline at 1-800-920-4343.
Are you located in or primarily serving residents of South Dakota?

YesNo
This program is for organizations located in or primarily serving South Dakota. If you are outside of South Dakota, get connected with local services in your area by dialing 211 or visit 211.org.
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
If out of South Dakota use the option 'Out of State' (bottom option)
How many packets would you like to receive?*
You can receive up to 5 packets.
Admin
Should be Empty: