Whatcom County Naloxone Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

***PLEASE READ BEFORE COMPLETING FORM***

This form is designed to request Naloxone, commonly called Narcan. Naloxone is a medication that can help reverse an opioid overdose.

This program provides Nasal Naloxone Kits at no cost for Whatcom County (WA) individuals and groups who would otherwise be unable to afford them.

Our supplies are limited. We will notify requesters when their request is ready for pickup or if we cannot fulfill the request. Please wait for notification before trying to pick up your request. Requesters must be able to pick up their requested kit(s) at 509 Girard St., Bellingham. Pick up is available Monday through Friday, between 8:30am and 4:00pm (excluding holidays).
Only Individuals, groups, and businesses in Whatcom County (WA) are eligible. If you are not a Whatcom County resident but live in Washington State, or live in Whatcom County and need to request mail delivery, make a request to the Washington State Naloxone Mail Order form instead.

Individual requests will receive one kit. Businesses, Community Groups, or Nonprofits can receive multiple kits depending on the nature of the request and availability

Name *

Please provide first and last name.

Are you replacing a kit (or kits) used during an overdose? *

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.