Deterra Request Form

Deterra Request Form
Deterra medication disposal pouches are a safe, easy-to-use way to deactivate and dispose of substances at home. Simply add up any substance (pills, powder, liquid, patches, creams, etc) and warm water to the bag, seal it, and throw it away. When used correctly, any medications in the bag become inert and unable to be used.

Your requested Deterra medication disposal pouches will be ready for pick up at Jackson County Public Health within one business day of your request. Please plan to pick up within three business days.

Note: If you are requesting Deterra on behalf of an organization or are seeking more than 2 pouches, please reach out directly to (816) 404-6493 or healthpromotions@uhkc.org.
Name*
Your name will only be used to coordinate pick up. You may use a nickname or initials.
Email
Used to confirm receipt of your request and let you know when it is ready for pickup.
What is your zip code?*
Type "NA" if you prefer not to answer.
What is your age?*

18 - 24 years old25 - 34 years old35 - 44 years old45 - 54 years old55 - 64 years old65 years old or olderPrefer not to answer
What is your race?*

American Indian or Alaska NativeAsianBlack or African AmericanNative HawaiianTwo or more racesWhiteI only identify as Hispanic/LatinoPrefer not to answerOther
Do you identify as Hispanic or Latino/a/e?*

Yes, Hispanic or Latino/a/eNo, not Hispanic or Latino/a/ePrefer not to answer
Should be Empty: