Woman completing a Regional Municipality of Durham online form on a computer.

Form Builder

Home Health and WellnessHealth Care Professionals

Required fields are marked with asterisks (*)

Naloxone Kit Order Form for Registered Sites

Registered Sites Only

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

Please 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 details:
Regional Municipality of Durham Headquarters
605 Rossland Rd. E, 2nd Floor, Whitby L1N 0B2
Monday to Friday, 8:30 a.m. - 4:30 p.m.

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