Narcan Kit Request Form
Available to residents and businesses in Huntington Beach only.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this personal or business address?
*
personal
business
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
To help us assist you, could you share what led you to consider having Narcan at your residence or business?
*
Submit
Should be Empty: