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w <br /> ve <br /> Pharmaceutical Waste <br /> Return Receipt <br /> Page 1 <br /> Return expired medications from: Kit Number: <br /> Office Location: <br /> Address: <br /> To insure your receipt of expired drugs your signature is requested and the <br /> return of this form to the above address. Thank you for your assistance. <br /> Health First Corporation Information: <br /> DATE: <br /> RECEIVED BY: <br /> PRINT NAME <br /> SIGNATURE: <br /> List of Pharmaceutical Waste returned: Amount: <br /> 1. Ventolin Inhaler <br /> 2. Benadryl <br /> 3. Adrenalin <br /> 4. Nitrolingual Spray <br /> 5. Ammonia Inhalants <br /> 6. Epinephrine Injection <br /> Page 2 <br /> Quality/OSHA Master Gray Original 109 Pharmaceutical Disposal Program (10-01) <br />