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P-10, r. 14 - Regulation respecting the disposal of medications and poisons following the permanent closing of a pharmacy
Schedule II
Versions
FORM B
(s. 2.02)
_________________________________________________________________________________
| |
| (Seal of the Order) |
| |
| THE ORDRE DES PHARMACIENS DU QUÉBEC |
| |
| Remittance of medications and poisons other than controlled substances and |
| controlled drugs to an authorized person by a pharmacist permanently closing |
| his pharmacy |
| |
| I, the undersigned, Mr, Ms .................................................... |
| (name) (given name) | | |
| ............................................ domiciled at ..................... |
| (profession) (address) |
| |
| ............................................................................... |
| (street) (municipality) (telephone) |
| |
| and practising my profession at................................................ |
| (address) (street) |
| |
| ............................................. or (in the case of a wholesaler, |
| (municipality) (telephone) |
| |
| a hospital, etc.), Mr, Ms ..................................................... |
| (name) (given name) |
| |
| ...................................................................employee of |
| (function within the institution concerned) |
| |
| ................................................................... located at |
| (name of institution) |
| |
| ............................................................................... |
| (address) (street) (municipality) (telephone) |
| |
| hereby declare that I have concluded an agreement with Mr, Ms ................. |
| |
| ............................................................................... |
| (name) (given name) |
| |
| pharmacist, practising his (her) profession at ................................ |
| |
| ............................................................................... |
| (address) (street) (municipality) (telephone) |
| |
| on .................................................., in order to acquire all |
| (day) (month) (year) |
| |
| or part (indicate the percentage.....%) of the medications and poisons, other |
| than controlled substances and controlled drugs, in his (her) possession on the |
| date fixed for the permanent closing of his (her) pharmacy. |
| |
| And I declare that I am a person authorized under the Act to possess and sell |
| the said medications and poisons. |
| |
| |
| |
| |
| |
| ................................... |
| signature of the acquirer |
| |
| Date: .................20...... |
|_________________________________________________________________________________|
