Please Note: If you are choosing to receive Naloxone at no cost, all information must be filled out and will be shared with VDH and Truax Pharmacy for the sole purpose of providing the Naloxone to you.  If you do not wish to receive Naloxone, this information will not be shared. 

* 1. Do you want to accept this Naloxone provided by VDH and Truax Pharmacy? (This requires your registration information to be shared with VDH and Truax Pharmacy for the SOLE purpose of purchase and fulfillment of this prescription)

* 2. Training location:

* 3. Training date:

Date / Time
/
/

* 4. First Name

* 5. Last Name

* 6. Home Street Address

* 9. Home Zip Code

* 10. Home Phone Number

* 11. Email Address

* 12. Date of Birth

Date
/
/

* 13. Gender

* 14. Race

* 15. Do you consider yourself Hispanic/Latino?

* 17. I understand that by checking this box, I give DBHDS the right to share the information I have provided here with the Virginia Department of Health and Truax Pharmacy for the sole purpose of providing Naloxone to me.

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