R-Jax Narcan Request Form

Free Narcan Request Form

Rebel Recovery Jax provides free Narcan to anyone in Duval or Nassau County.
Accessing Mail-Based Narcan (Florida residents only)

Do you live in Florida and need Narcan mailed to you? Please visit: https://nextdistro.org/flchoice
Accessing Narcan In-Person

Want to obtain Narcan from a community provider in Florida? Please visit: https://isavefl.com/find-naloxone.html
Accessing Narcan Nationwide

Don't live in Florida and don't know where to access Narcan? Please visit: nextdistro.org/naloxone
Yes, Duval CountyYes, Nassau CountyNo, but I will be in Duval/Nassau County and need access to NarcanNo, I do not live in either counties
I will stop by the office (3811 Blanding Blvd Jacksonville, FL 32210, anytime between Mon-Fri 9am-5pm)I am requesting Narcan delivery
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address (needed if you are requesting Narcan delivery)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNoUnsure
in case I ever run into someone who has overdosed in a public spaceto protect someone I know from a fatal overdosebecause I work with/around people who are using substancesbecause I am a Professional First ResponderOther
How many Narcan kits are you requesting?
Demographics

Please help us gain a better picture of the community's needs by entering your demographic information. This helps us to make changes based on what community members changing needs are.
Age of person requesting Narcan
ManWomenBigender/PangenderNon binary/Gender NonconformingGenderfluidAgenderNot sure/QuestioningTwo-SpiritIdentity not listed herePrefer not to answerOther
American Indian/Native American, or Alaskan NativeAsianBlack or African AmericanHispanic or LatinxMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhite or CaucasianDon't knowPrefer not to answerOther
I don't know where to get itI can't get it at the places it's available due to office hoursI can't get it at the places it's available due to location/lack of transportationI can't afford itI don't want to be seen going to the places where it's availableIts out of stock at the place I normally go toThe pharmacy won't sell it to meNoneOther
Web searchFLHRC.orgisavefl.comI've received Narcan from you previouslySocial media postHeard about it through someone elseOther
Thank you for caring!

We will reach out as soon as we can!
Check out this 4-minute video on how to identify an Opioid Overdose and Administering Narcan.

https://www.youtube.com/watch?v=9ZmSXQfi74k
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Free Narcan Request Form

Accessing Narcan Nationwide

Demographics

Thank you for caring!