Send a Narcan Request

This is a form to receive bulk shipments of free Narcan, monthly. Our Narcan is supplied by state-specific government agencies. Currently available in Allegheny county, PA; Hillsborough county, FL; Pinellas county, FL; Alachua county, FL. If not available in your area, contact us through our website.

Organizational Information

What is your organization's name?

What state is your organization located in?

What county is your organization located in?

Provide an email to contact the organization:

Narcan Shipment Information

Are you filling out this survey while in your community?

YesNo

Provide an address of the nearest park in your area:

Provide a phone number within your organization that can respond to monthly Narcan:

How many boxes of Narcan do you need?

What is your availability this month? (add at least one date)

Receive monthly deliveries?

YesNo

I agree to the Terms of Service