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NALOXONE INTAKE FORM(standard)FOR OFFICE USE ONLY Distribution Setting:Form identification number: Date of Kit Distribution: _/_/ Number of kits provided:__0 Community Access Point 0 Corrections/Court

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How to fill out naloxone intake form individual

01

Obtain the naloxone intake form from a healthcare provider or pharmacy.

02

Fill out your personal information including name, address, date of birth, and contact information.

03

Provide any relevant medical history, allergies, and current medications.

04

Indicate your level of understanding of naloxone and emergency procedures.

05

Sign and date the form to acknowledge your consent and understanding of naloxone use.

Who needs naloxone intake form individual?

01

Individuals who have been prescribed naloxone by a healthcare provider.

02

Individuals who are at risk of opioid overdose or may witness an overdose.

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What is naloxone intake form individual?

Naloxone intake form for individuals is a document used to record information about the administration of naloxone, a medication used to reverse opioid overdose.

Who is required to file naloxone intake form individual?

Healthcare professionals, first responders, and individuals trained in administering naloxone are required to file naloxone intake forms.

How to fill out naloxone intake form individual?

To fill out the naloxone intake form, one must provide details of the person receiving naloxone, the dosage administered, the date and time of administration, and any observations or follow-up actions taken.

What is the purpose of naloxone intake form individual?

The purpose of the naloxone intake form is to document the use of naloxone in reversing opioid overdoses and to track trends for public health analysis.

What information must be reported on naloxone intake form individual?

Information such as patient demographics, naloxone dosage and administration details, location of overdose, and any adverse reactions must be reported on the form.

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