Narcan Order - Epidemiology

NARCAN® Order Form

Please use this form to place an order if your organization currently has a fully-executed agreement with the Virginia Department of Health for provision of Narcan. For questions filling out this form, please contact pharmacyvisions@vdh.virginia.gov.

Type of Organization*
Site Name*
MOU Number*
Law Enforment and Fire Services (non-EMS licensed) MOUs should have 12 characters. CSB/CHR MOUs should have 13 characters.
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
Name*
Please enter the name of the best contact person related to this order.
First Last
Email*
Please enter the best email address for contact purposes related to this order.
Enter Email Confirm Email
Number of Kits (less than 100)*
NOTE: if you need more than 100 kits, please insert 0 into this field. PLEASE ONLY ORDER ONE MONTH'S SUPPLY. You can submit orders as frequently as needed. Ordering a month at a time ensures that you receive the best dating and wastage is prevented.
Please enter a number from 0 to 100.
Check below if you need more than 100 kits:
- I need more than 100 kits
Number of Kits (more than 100)*
Please enter a number greater than or equal to 100.
More Than 100 Kits Justification*
Please use the box below to explain the need for such a large quantity.
Will any of these kits be used for dispensing?*
If no, we assume you only plan to administer kits upon arrival to an overdose and do not plan to "leave one behind."
- Yes
- No
How many of the quantity ordered above do you plan to use for dispensing?*
This lets VDH know how many labels to send. Note: this number is a subset of the quantity ordered above; it is not in addition to. As a result, this number cannot be more than the number of kits ordered.
Please enter a number greater than or equal to 1.
Are gloves and masks needed for any of the NARCAN® kits (i.e. you will not be providing REVIVE! training kits)?*
- Yes
- No
Please enter the number of NARCAN® kits that you need supplies (gloves and masks) for:*
Note: The number here cannot be higher than the number of NARCAN® kits in this order.
Please enter a number greater than or equal to 0.