Naloxone Request Form

Vermont Naloxone/ Narcan Request Form

In an effort to streamline our processes we have developed this form to ensure we have all the required information to process your request.

Please allow up to 2 weeks to receive the shipment. If you have any questions or concerns, please email naloxone@vermont.gov or include your question in the additional requests at the bottom of the form.
Thank you!

1. Organization Name *This question is required.

2. Point of Contact

First Name

Last Name

Title

Street Address

Apt/Suite/Office

City

State

Zip

Email Address

Phone Number

4. Please indicate your organization type (Choose One) *This question is required.

Please enter an 'other' value for this selection.