PHARMACIES ONLY: NALOXONE EDUCATION BROCHURE REQUEST

To assist Ohio Pharmacies in the distribution of naloxone, the Board of Pharmacy is offering all Ohio pharmacies copies of its naloxone patient counseling brochures. The Board is currently offering these resources in English only. However, digital copies in several languages may be downloaded by visiting: www.pharmacy.ohio.gov/naloxone.

Due to high demand orders are limited to 200 brochures. Additional orders may be placed if a pharmacy is running low.

PLEASE ALLOW 7-10 BUSINESS DAYS FOR DELIVERY.

For any questions regarding this form, please contact the Board via email at: contact@pharmacy.ohio.gov.

Question Title

* 1. Contact Information

Name of Licensed Ohio Pharmacy

Full Name of Contact Person

Mailing Address

City/Town

State/Province (Ohio Locations Only)

ZIP/Postal Code

Email Address

Phone Number

PHARMACIES ONLY: NALOXONE EDUCATION BROCHURE REQUEST

Question Title

* 1. Contact Information

Question Title

* 2. Number of Naloxone Patient Counseling Brochures