Naloxone Mail Order Request Form
Naloxone rescue kit order form:
Naloxone (Narcan or Kloxxado) can reverse an overdose caused by an opioid drug (some examples: heroin, fentanyl, and types of pain medications). Family members, friends, and coworkers of someone who uses drugs, someone who is in an opioid recovery program, or someone who is prescribed opioid pain medications should have a Naloxone rescue kit on hand.

No private information will be shared. Questions on this form are adapted from Harm Reduction Ohio. Project DAWN, Naloxone distribution program, is funded by a grant through the Ohio Department of Health. A copy of MCHD’s privacy statement is available upon request. If you have questions about this form, please contact MCHD at 330-723-9688, option 2. Ask to speak with a Public Health Nurse who dispenses Naloxone.

Steps:
1) Complete this form
2) Watch the training video
3) Submit this form

MCHD will process your order in 2-3 business days of completing this form. You have 2 options to receive your kit:
1. Lobby pick-up (M-F: 8:30 AM – 4:00 PM). Note: after 7 business days the kit will be returned to inventory.
2. Mail order (Allow an additional 3-5 business days for mailing service)

Medina County Health Department HIPAA Policy:
https://medinahealth.org/wp-content/uploads/HIPAA-Notice-of-Privacy-Practices-Revised-7.19.17.pdf
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Todays Date *
MM
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First Name *
Last Name *
Address *
City *
Zip *
County *
Phone *
Email *
Number of Kits Being Requested *
Would you like your Naloxone kit mailed or picked up from the health department? MCHD will process your Narcan rescue kit order or be ready for pick-up or mailed out in 2-3 business days. *
Please Watch Training video by the Ohio Department of Health:
https://youtu.be/dBF0ovVWPYc
I agree that I have watched the ODH Naloxone training Video above. *
Required
Please Read and Initial
1) Additional Information:
o 911 needs to be called when identifying an overdose.
o The Naloxone can be given to someone overdosing even if the source of the drug is unknown.
o The entire amount of Naloxone spray is given regardless of the person’s size or age.
o Wait 2 minutes before giving each additional dose of Naloxone.
By initialing this line, I agree that I have read and understand the above mentioned additional information for administering Naloxone. *
Expiration, Storage, and Refill:
o The expiration date is listed on bottom of the box and the medication is valid until last day of the month.
o To store Naloxone (Narcan 4mg or Kloxxado 8mg) at room temperature, do not freeze, and protect from light (leave in blister packs and box provided.)
o To refill Naloxone kit (if expired or used) an order can be place through MCHD Project DAWN website or call (330) 723-9688 (option #2) and speak with a Public Health Nurse.
By initialing this line, I agree that I have read and understand the above mentioned expiration, storage, and refill for Naloxone. *
Age *
Required
Which gender do you most identify with? *
What race(s) and ethnicity do you consider yourself? (Check All That Apply) *
Required
In which Ohio zip code do you live? *
In which Ohio county do you live? *
Have you used drugs in the last year (other than marijuana)
Clear selection
Have you ever overdosed or witnessed an overdose
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Is this the first naloxone (Narcan) kit you have received? *
Intended use for Naloxone *
How did you hear about us?
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