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 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!

1. Organization Name *This question is required.

2. Point of Contact

First Name *This question is required.

Last Name *This question is required.

Title

Street Address (Please use a physical address if you are requesting more than 15 doses-- we ship larger amounts via UPS and cannot deliver to a PO Box) *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

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

Please enter an 'other' value for this selection.