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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 sites which which currently receive naloxone through our program. If you are an organization looking to become a new distribution site, please email

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.