Naloxone 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 note that this form is only for organizations who have previously received naloxone through our program, or who have gone through the process to become a new distribution site.

If you are looking to become a new distribution site, please email naloxone@vermont.gov.

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!