Medical Lockbox Request Form

Medical Lockbox Request

More than 60,000 young children end up in emergency rooms each year because they got into medicines while their caregiver wasn’t looking. Every day in the United States, an average of 2,000 teenagers use prescription drugs without a doctor’s guidance for the first time.

Safeguard medicine in your home and take extra precautions with: Pain Pills, Anxiety Medicine, Insulin Syringes, Anti-Depressants, Sleeping Pills, ADHD Medicine, and other strong medicine.

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Name(Required)

Address(Required)

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Type of Request

Individual

Non-Profit Organization

For-Profit Organization

Organization Name

Number of Boxes Requested

Please enter a number from 1 to 30.

Please Check All that Apply

I have a home (or organization) where children live or frequently visit.

My organization serves youth (school, daycare, after-school program, etc.).

I am an older adult (or an organization that serves older adults).

I have recently had my medication stolen.

Medical Lockbox Request

Medical Lockbox Request Form

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