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P-10, r. 14 - Regulation respecting the disposal of medications and poisons following the permanent closing of a pharmacy
Schedule
Disposition versions
FORM A
(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) |
| |
| pharmacist, practising my profession at ....................................... |
| (address) |
| |
| ............................................................................... |
| (street) (municipality) (telephone) |
| |
| give notice to the secretary of the Order that on............................., |
| (day) (month) (year) |
| |
| I concluded an agreement with Mr, Ms .......................................... |
| (name) (give name) |
| |
| ............... domiciled at and practising his (her) profession at............ |
| (profession) |
| |
| ............................................................................... |
| (address) (street) (municipality) (telephone) |
| |
| or (in the case of a wholesaler, a hospital, etc.) with ....................... |
| |
| ................................................................., located at |
| (name of institution) |
| |
| ............................................................................... |
| (address) (street) (municipality) (telephone) |
| |
| in order to dispose of all or part (indicate percentage..%) of the medications |
| and poisons, other than controlled substances and controlled drugs, in my |
| possession on the date fixed for the permanent closing of my pharmacy. |
| |
| I certify that, to my knowledge, the acquirer hereinabove mentioned is a |
| person authorized under the Act to possess and sell the said medications |
| and poisons. |
| |
| |
| |
| ..................................... |
| signature of pharmacist-vendor |
| |
| Date: ..................20...... |
| ________________________________________________________________________________|
