Community Narcan Order Form
This Narcan is available for request by any local organization who is working with community members at risk for overdose, or family members who may be in a position to reverse overdose. This Narcan must be distributed by your organization to members of the public at NO COST.
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Contact Number
*
Organization Requesting Narcan
*
Organization Name
Quantity of Intranasal Narcan Kits Needed
*
Please Select
6 Kits
12 Kits
18 Kits
24 Kits
More Than 24 Kits (Please provide QTY and detail of request in the next section)
Special Instructions
If you are requesting more than 24 Narcan Kits or have additional information please provide details here.
Signature
*
By signing, the organization agrees to the following terms: Distribution: The organization will disperse the intranasal Narcan doses at no charge to patients and their families who are in need. Training: The organization will provide appropriate training on the administration of intranasal Narcan to recipients. Reporting: The organization will maintain records of Narcan distribution, including the number of doses dispensed and any relevant recipient information. Liability: The organization acknowledges that it assumes all responsibility for the proper use and distribution of the provided intranasal Narcan doses.
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