Take Home Naloxone Application

Scottish Families will keep your information confidential and will not share it with third party organisations or use it for marketing purposes. We record statistics to monitor areas where we have distributed naloxone kits and the information we collect are your initials, age, first part of your postcode (i.e. EH11) and reason for issue. If you are happy for us to collect this information we can issue you with a kit, please complete the form below.

If you are interested in finding out more information on preventing overdose and how to give naloxone, Scottish Drugs Forum has created a short e-learning courses on opiate overdose prevention, intervention and naloxone. We recommend to anybody who would like a naloxone kit to complete this online training before using naloxone.

The online course is free and available here.

Naloxone Application

Where did you hear about this service?

Who is the
naloxone for? *

Please select which Naloxone product you require... *

What was your reason for choosing this product? *

Click here for more information on Nyxoid
Click here for more information on Prenoxad

Is this your first
naloxone kit? *

Training Declaration *

“I have undertaken the recommended SDF E-learning course or have previously received Naloxone training. I am aware of the signs of opioid overdose, how to provide basic life-support and naloxone use”

I agree to the training declaration

NOTE : If you do NOT agree to the training declaration, leaving a mobile contact number will be mandatory, so we can give you a quick call to provide training on how to administer the Naloxone.

Your Details

First Name *

Last Name *

Date of Birth * / /

Address line 1 *

Address line 2

Town / City *

Post Code *

Phone Number

Optional; will be used to update the applicant on any issues around shipping. Mandatory if you do NOT tick the Training Declaration.

Email Address

Optional; will be used to update the applicant on any issues around shipping

Would you like to offer any feedback on the application process or service improvements ?

Yes No