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Switching to Heartland
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Equipment Request Form

Once this ticket has been submitted, a Heartland Pharmacy representative will contact you for solutions, costs and additional information regarding your equipment.

Name(Required)

Phone(Required)

Email(Required)

Community Name(Required)

Community Address(Required)

Scanner Issues:

Med Cart Serial Number:

Lock Issues:

Keys:

Narc Box/Drawer

Sharps

Main Cart

Rails:

Additional Equipment Requests:

More Information:

Do you need Med Destruction Liners?

Yes

No

To order out-of-schedule liners, please call Sharps Compliance, Inc. at 800.772.5657 or fill out the information below. By completing this form, you and your community agree to pay the $270/liner plus a processing fee.

Name

Email

Community Name

Community Address

Liner Size

For laptop and fax machine questions, trouble shooting, etc. please call Treasure Valley IT at 208-367-1000 or help@tvit.net.

*Please be aware that service fees and charges may apply to this ticket and request.

Corporate Office

1790 Sabin Drive Ammon, ID 83406
(208) 497-3575

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Name*
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Community Name
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