Medication Lock Box and DisposeRX Request Form

Medication Lock Box and DisposeRX Request Form
Please complete this form to have one Medication Lock Box and/or DisposeRX packets sent directly to you. Organizations can have up to 7 Medication Lock Boxes sent to their organization. Medication Lock Boxes and Dispose RX packets are only distributed to South Dakota residents and organizations. Please allow 1-2 weeks for delivery. Questions? Please reach out to 988 or email substanceuse@helplinecenter.org.
Are you located in South Dakota?
This program is for South Dakota residents and organizatons only. If you are outside of South Dakota, get connected with local services in your area by dialing 211 or visit 211.org.
What are you looking to receive?
Are you ordering Medication Lock Boxes for personal or organizational use?
For organizations only: Be on the lookout for an email regarding mandatory reporting guidelines for lockbox requests
How many packets would you like to receive?
Name

First NameLast Name
Organization Name
Email
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
If out of South Dakota use the option 'Out of State' (bottom option)
Is Mailing Address different?
Mailing Address (If applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Additional concerns / questions:
Should be Empty: