Online Request Form for Deterra Pouches
RequiredRequired Question(s)
Permanently destroy prescription and over the counter medications in three simple steps from the comfort of your own home. Made with non-toxic materials, the easy-to-use Deterra pouches are proven to deactivate medication in a safe, eco-friendly way.

In an effort to comply with social distancing guidelines, we will be mailing Deterra pouches to your home. Please provide your home address below. Once you complete the survey, you should expect to see your Deterra pouches in the mail in 7-10 business days.

Thank you for supporting safe disposal & prevention!

 
Required 1.

Full Name: 

 

50 characters left.
Required 2.

Email Address: 

 

50 characters left.
Required 3.

Are you a Delaware County resident? 

Yes
No
Required 4.

Street Address:

 

50 characters left.
Required 5.

City:

 

50 characters left.
Required 6.

Zip code: 

 

50 characters left.
Required 7.

How many Deterra pouches are you requesting?  

 *Current limit is 2 per Delaware County resident. However, if you need additional pouches, please contact us and we will be happy to work with you. 

1
2
Other  
The Deterra pouch distribution program is coordinated by Holcomb Behavioral Health Systems and is funded by the Delaware County Office of Behavioral Health, Division of Drug and Alcohol.