Narcan Order 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*Community Services BoardIndependent Health Department (Arlington or Fairfax)Comprehensive Harm Reduction ProgramLaw EnforcementFire Service (non-EMS licensed)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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the shipping address the same as the physical address?*YesNoShipping Address*Note: We cannot ship to P.O. Box addresses. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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."YesNoHow 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)?*YesNoPlease 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.
