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NALOXONE INTAKE FORM INDIVIDUAL DISTRIBUTION FOR OFFICE USE ONLY Form identification number: ___ Date of Kit Distribution: ___/___ /___ Number of kits provided: ___ How is this naloxone funded? ODD
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How to fill out naloxonenaloxone intake form
How to fill out naloxonenaloxone intake form
01
Obtain naloxone intake form from a healthcare provider or pharmacy.
02
Fill out your personal information such as name, date of birth, and contact information.
03
Provide details about your medical history, current medications, and any allergies you may have.
04
Answer questions about your history of opioid use and any prior experience with naloxone.
05
Sign and date the form to acknowledge that the information provided is accurate.
Who needs naloxonenaloxone intake form?
01
Individuals who have been prescribed naloxone for the treatment of opioid overdose.
02
Caregivers or family members of individuals at risk of opioid overdose.
03
Healthcare professionals who may need to administrate naloxone in emergency situations.
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What is naloxonenaloxone intake form?
The naloxonenaloxone intake form is a document used to record the administration of naloxone in cases of opioid overdose.
Who is required to file naloxonenaloxone intake form?
Healthcare professionals and emergency responders are required to file naloxonenaloxone intake form after administering naloxone.
How to fill out naloxonenaloxone intake form?
The form typically requires details such as the date and time of administration, the patient's information, the dosage given, and any additional notes about the incident.
What is the purpose of naloxonenaloxone intake form?
The purpose of the naloxonenaloxone intake form is to document the administration of naloxone during an opioid overdose and ensure proper medical records are maintained.
What information must be reported on naloxonenaloxone intake form?
Information such as the date and time of administration, patient's details, dosage given, and any relevant notes about the incident should be reported on the naloxonenaloxone intake form.
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