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NALOXONE REQUEST FORM First responder agencies (i.e., law enforcement/corrections, fire/EMS) whose staff have completed opioid overdose recognition and treatment training consistent with ADDS or AZ

How to fill out naloxone request form

How to fill out naloxone request form

1. To fill out the naloxone request form, follow these steps:
2. Obtain a naloxone request form from a healthcare provider or a local pharmacy.
3. Read the instructions on the form carefully to understand the requirements and guidelines.
4. Provide your personal information, such as your full name, date of birth, and contact details.
5. Specify your current address and any additional information required for proper delivery.
6. Indicate the quantity of naloxone kits you are requesting.
7. Answer any additional questions or provide any necessary information about your medical history or reasons for requesting naloxone.
8. Sign and date the form to validate your request.
9. Submit the completed form to the healthcare provider or pharmacy as instructed.

Who needs naloxone request form?

1. Individuals who are at risk of opioid overdose or who may be in contact with individuals at risk of opioid overdose should fill out a naloxone request form.
2. This can include individuals who are prescribed opioid medications, those who use opioids recreationally, friends and family members of individuals who use opioids, and healthcare professionals.
3. Naloxone is a life-saving medication that can reverse the effects of an opioid overdose, so anyone who may encounter such emergencies can benefit from having access to naloxone by filling out the request form.

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What is naloxone request form?

The naloxone request form is a document used to request naloxone, a medication used to reverse opioid overdose.

Who is required to file naloxone request form?

Individuals or organizations who want to obtain naloxone are required to file the naloxone request form.

How to fill out naloxone request form?

To fill out the naloxone request form, provide necessary information such as contact details, quantity of naloxone needed, and purpose of use.

What is the purpose of naloxone request form?

The purpose of the naloxone request form is to facilitate the process of obtaining naloxone for use in reversing opioid overdoses.

What information must be reported on naloxone request form?

Information such as contact details, quantity of naloxone needed, purpose of use, and any other relevant details must be reported on the naloxone request form.