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Tanana Chiefs Conference Division of Wellness and Prevention Opioid Harm Reduction Request Form
Available for anyone living within the Tanana Chiefs Region
Please help us by providing some general information
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1.
Today's date
(Required.)
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2.
Please provide your zip code
(Required.)
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3.
What are you requesting?
(Required.)
Naloxone Opioid Overdose Reversal Spray
Deterra- Safe Medication Disposal Pouches
Both Naloxone and Deterra
Fentanyl and/or Xylazine Testing Strips
All the above
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4.
If you want the kits mailed to you, please provide all the following information. Minimally please provide your name and a way to contact you if we need to clarify anything prior to sending
(Required.)
First & Last Name
*
Professional Position (if applicable to request)
Mailing Address for kits
City/Town
Zip code
Phone number or e-mail if we need to contact you
*
