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Application for Naloxone Agreement with the Virginia Department of Health

Please complete this form if your organization would like to request naloxone and/or test strips through the Virginia Department of Health for the first time, or if your organization's agreement with VDH has expired. A fully executed agreement with your organization must be on file before VDH can provide naloxone or test strips.
Please note that VDH is only providing test strips to a limited number of eligible partners at this time.
For questions filling out this form, please contact opioidreversal@vdh.virginia.gov.
Thank you!

federal agencies warning

  • Federal agencies should contact opioidreversal@vdh.virginia.gov before applying for a naloxone agreement.
  • VDH cannot ship to P.O. Boxes.
  • A red star (*) or a red upper left edge indicates that a field is required.
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