Narcan Application - Epidemiology

NARCAN® Application Request

Please use this form if your organization would like to request Narcan through the Virginia Department of Health for the first time or if your organization's agreement with VDH has expired. A fully-executed agreement must be on file with your organization before VDH can provide Narcan. For questions filling out this form, please contact pharmacyvisions@vdh.virginia.gov.

Type of Organization*
Site Name*
Contact Person's Name*
Please enter the name of the person that should be contacted with regard to this request.
First Last
Contact Person's Phone Number*
Please enter the best number to use to reach a contact person for questions related to this request.
Contact Person's Email*
Please enter the best email for contact purposes related to this request. The agreement will be sent to this email. (NOTE: please make sure to enter a valid email address in this field.)
Enter Email Confirm Email
Physical Address*
Street Address Address Line 2 City State ZIP Code
Is the shipping address the same as the physical address?*
- Yes
- No
Shipping Address*
NOTE: We cannot ship to P.O. Box addresses.

Street Address Address Line 2 City State ZIP Code