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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 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 fill out the New Site Screening Form at

Please allow up to 2 weeks to receive the shipment. If you have any questions or concerns, please email or include your question in the additional requests at the bottom of the form. 
Thank you!
2. Point of Contact
This question requires a valid email address.
4. Please indicate your organization type (Choose One) *This question is required.