Required fields are marked with asterisks (*)

Naloxone Kit Order Form for Registered Sites

Registered naloxone distribution sites only

If you are not a registered naloxone distribution site, please complete our Naloxone Distribution Program Eligibility Application.

Plan ahead to avoid shortages.
Please return any expired naloxone kits to your nearest pharmacy.

Durham Region Health Department will contact you by phone or email when your order is ready for pick-up.

Pick-up is by appointment only.
Regional Municipality of Durham Headquarters
605 Rossland Rd. E., Whitby L1N 0B2

Contact information:

Agency Name

Contact First Name

Contact Last Name

Phone Number

Email Address

Current inventory:

Current number of naloxone nasal spray kits in stock:

Current number of naloxone nasal refill boxes in stock:

Monthly ordering: typical order sizes

Assembled kits:

New site: 10 kits
Smaller site: 20 kits
Larger site: 50 kits

Refills:

New site: 5 boxes
Smaller site: 10 boxes
Larger site: 25 boxes

Your product order:

Requested number of assembled naloxone nasal spray kits:

Requested number of naloxone nasal refill boxes (two doses of 4 mg naloxone nasal sprays per box):

Information is collected and used under the authority of the Health Protection and Promotion Act R.S.O. 1990 cH.7, s.5. This information is collected and used for the purposes of substance use prevention and harm reduction, reporting and providing you with naloxone kits. Questions about this collection and use of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, ON, L1N 0B2, (905) 668-7711.