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Naloxone Request Form

Vermont Naloxone/ Narcan & Harm Reduction Supplies Request Form

In an effort to streamline our processes we have developed this form to ensure we have all the required information to process your request. Please note that this form is only for organizations who have previously received naloxone through our program, or who have gone through the process to become a new distribution site.

If you not yet an established site and are looking to become a new distribution site, please fill out the New Site Screening Form at http://s.alchemer.com/s3/Naloxone-New-Site-Screening

Please allow up to 3 WEEKS to receive the shipment. If you have any questions or concerns or are in URGENT need of supplies, please email naloxone@vermont.gov or include your question in the additional requests at the bottom of the form. 
Thank you!
2. Point of Contact
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4. Please indicate your organization type (Choose One) *This question is required.
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