BPHC Naloxone Request Form

Organizations in Boston can use this form to request naloxone in bulk via the Boston Public Health Commission. Local organizations are well-positioned to distribute naloxone throughout neighborhoods, helping to prevent overdoses. The form assists BPHC in triaging requests and coordinating pick up and delivery. BPHC has limited ability to deliver naloxone and welcomes organizations picking up the kits from the 774 Albany Street location.

IMPORTANT: BPHC can only provide naloxone once to organizations and all requests are capped at 36 kits. We typically need two weeks of lead up time to coordinate a hand-off but in some occassions may process orders faster. BPHC can ONLY distribute kits to organizations located in, or operating out of Boston.

Naloxone distribution is supported by Boston Overdose Data to Action. The Massachusetts Bureau of Substance Addiction Services runs the Community Naloxone Program, which BPHC leverages as a vital source for this medication.

The form is NOT for individuals to request naloxone. Individuals can learn more about how to get naloxone on the BPHC Overdose Prevention website.

Name of requester?*

Requester phone number?*

Requester email?*

Name of organization?*

What type of organization are you? (Select the one that fits best)*

If you selected "Other organization"," could you please describe your organization?*

How many kits are you looking for? Each kit contains 2 doses. Please be mindful about ordering too many kits, and them expiring unused. The cap is 36 kits.*

Are you able to pick up the kits from 774 Albany Street?

Can pick up the kitsCannot pick up. Need BPHC to deliver

By what date are you seeking to get naloxone?*

Please share any other relevant information about your request or how you plan to distribute the kits, like at a particular event or activity.

Which Boston neighborhoods do you serve?*

What's the zip code of your organization?*

Any additional comments or feedback?

Boston OD2A is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $2,710,074.00 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.