Naloxone Request

Request Form - Naloxone and Fentanyl Test Strips
Please use this form to request free Narcan or fentanyl test strips for pickup at our office. Pickup details will be emailed to you automatically.

For any questions or concerns, please contact staff directly at info@sacopioidcoalition.org
First Name*
Last Name
Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Are you associated with an organization or professional entity?
What items would you like to pickup?*

Naloxone kits - includes resource brochure, 1 box of naloxone, CPR face shieldNaloxone boxes - Boxes with 2 doses of naloxone insideFentanyl test strips
How many boxes of naloxone would you like?
How many fentanyl test strips would you like?
If more than 100 boxes of naloxone or more than 300 fentanyl test strips requested, please list below:
Would you like to talk to a staff member for a short naloxone training or to discuss treatment resources?

Yes, naloxone trainingYes, treatment or harm reduction resourcesNo - just a pickup
When would you like to pick up the Narcan and/or fentanyl test strips?*
Should be Empty:

Request Form - Naloxone and Fentanyl Test Strips