Naloxone(Narcan) Order Form

Date of Request

Have you downloaded & reviewed the Narcan Training Material?
YesNo - https://www.youtube.com/watch?v=KEOq6fUWNtA

Please Upload Acknowledgement of Narcan Training

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Contact Name*

Date of Birth

Phone Number*

Address*

Email*

Gender*
MaleFemaleUndisclosed

Ethnicity/Race
African American/BlackAsianCaucasianHispanic/LatinoOther

Reason for Request

Select NARCAN Pickup Location
Behavioral Health Admin: 303 E Vanderbilt Way, San BernardinoMariposa Community Counseling Clinic: 2940 Inland Empire Blvd., OntarioRialto Behavioral Addiction Treatment Services: 850 E. Foothill Blvd., RialtoBarstow Behavioral Health: 1841 E. Main St. Ste. 218, BarstowPhoenix Community Counseling Center: 820 E Gilbert St. San BernardinoAmazing Place Clubhouse, 2940 Inland Empire Blvd., OntarioPathways to Recovery Clubhouse, 17053 E. Foothill Blvd., Ste. B, FontanaDesert Stars Clubhouse, 1841 E. Main St., BarstowSerenity Clubhouse, 12625 Hesperia Rd., Ste. B, VictorvilleTEAM House Clubhouse, 201 W. Mill St., San BernardinoAdelanto Health Center, 11336 Bartlett Ave. Ste. 11, AdelantoHesperia Health Center, 16453 Bear Valley Rd., HesperiaOntario Health Center, 150 E. Holt Blvd., 2nd Floor, OntarioSan Bernardino Health Center, 606 E. Mill St., 1st Floor, San BernardinoNeedles Health Center, 1406 Bailey Ave., Ste. D, Needles (open Monday-Thursday 7 a.m. - 5 pm.)