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Email *
First Name *
Last Name *
Phone Number  *
Race/Ethnicity  (check one) *
Gender Identity  *
If you chose "other" in the previous question, please specify below:
Is the individual Hispanic, Latino or Spanish? (check all that apply) 
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Age Group: *
Was the reversal successful? *
How many kits were used for the reversal? *
In what region did the overdose occur ? *
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