Med Lock Box Request

Med Lock Box request

One way to prevent accidental poisonings is by safely storing medication in your home. Please fill out the form below to request a medication lock box with educational material, while supplies last. Note: At this time, we're providing one medication lock box per family.
Requester's name*

First NameLast Name
Organization
Requester's email*
example@example.com
Phone number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Questions/comments
Med Lock Box receipt and acknowledgement

The purpose of the Med Lock Box program is to help reduce the risk of children accidentally swallowing medications they find on their own, by providing education and a locking container where medications can be stored. The education and Med Lock Box are offered as a free service.
Please acknowledge the following by checking each box:*

I have received education on the proper use of the Med Lock Box.I understand that it is important to use the Med Lock Box correctly and that the failure to do so will mean my child will not have the safety benefits that the container may provide.I understand that this program and program sponsors cannot guarantee the quality, safety or condition of the Med Lock Box.I understand that the program sponsors make no guarantees, warranties (expressed or implied),or promises as to the effectiveness of the provided Med Lock Box.
Should be Empty:

Med Lock Box request