Panhandle Health District SUD Supply Order Form

Full Name*

First NameLast Name

Job Title*

Organization*

Address - Please note we cannot mail supplies with Narcan in them or deliver to personal addresses*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

example@example.com

Contact Number*

Have you received naloxone training from Panhandle Health District?*

If you select no, a training may be required before items can be distributed. Any supplies containing naloxone (Narcan) will require training.

Are you going to pick up these supplies or do you need them delivered?*

We will contact the listed person above to schedule a pickup or delivery when supplies are ready.

My Products

NaloxBoxWall mounted opioid overdose rescue kit. Includes: 2 doses of 4mg intranasal naloxone, 1 breathing barrier device, instruction guide, mounting kit, safety seal breakaway tie.Size: 4.5" x 11.5" x 11"

$ Free Quantity

Opioid Overdose Rescue Kit Product Image

Opioid Overdose Rescue KitCarrying pouch. Includes: 2 doses of 4mg intranasal naloxone, 1 pair of gloves, 1 CPR face shield, instruction guide, community resource magnet.Size: 6.5" x 5"

$ Free Quantity

Deterra Disposal PouchDeactivates prescription drugs, pills, patches, liquids, creams and films in an easy 3-step system. This makes it safe for disposal in normal trash. Small: 15 pills OR 2 oz. liquid OR 2 patches Medium: 45 pills OR 6 oz. liquid OR 6 patches Large: 90 pills OR 12 oz. liquid OR 12 patches

$ Free

Size	Quantity
Small
Medium
Large

Medication Lock BoxLock up medications for the safety and health of those around you. Small: H 5.04" x W 8.35" x D 2.48" Four elastic straps for securing syringes, roomy mesh pocket and removable zipper pouch for improved organization. Medium: H 5.16" x W 6.85" x D 4.45" Capable of holding up to 8 standard sized pill bottles. Large: H 5.4" x W 11.88" x D 5.25" Includes elastic dividers for organization.

$ Free

Size	Quantity
Small
Medium
Large

Naloxone BrochureThis tri-fold brochure provides a brief overview of what naloxone is, what opioid are, what an overdose looks like and the easy steps to use naloxone. Also included our additional resources and links for more information.

$ Free Quantity

Not Scary to Carry PosterStyle A: Recognize an Overdose Style B: How to use Narcan

$ Free

Style	Quantity
A
B

Good Samaritan Law PosterEncourage people to use naloxone and understand they are protected by law when calling 9-1-1 in an emergency.

$ Free Quantity

Safe Sharps Disposal Poster Product Image

Safe Sharps Disposal PosterShows all the various ways to dispose of sharps in our 5 north counties or what to do if sharps are found.

$ Free Quantity

North Idaho Substance Use Resources Poster Product Image

North Idaho Substance Use Resources PosterProvide resources with QR code links to free Narcan and recovery resources.

$ Free Quantity

Call Me Anti-Stigma Campaign Product Image

Call Me Anti-Stigma CampaignStyle A: Don't Call Me "Addict" (Substance Use Disorder) Style B: Don't Call Me "Crazy" (Mental Health) Style C: Don't Call Me "Dirty" (Homelessness) *Styles may vary with people and phrases

$ Free

Style	Quantity	Type
A
B
C

Community Resource Map Magnet Product Image

Community Resource Map MagnetThe QR code is attached to our Community Resource Map which provides locations and services in our 5 northern counties. These services include: treatment, housing, employment, support groups and much more! Size: 1.75" x 3.5" (Standard business card size)

$ Free Quantity

Total

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