Community Based Naloxone Program
Overdose Kit Use Reporting Form
For any patients returning to your pharmacy to obtain a replacement overdose kit, please provide a copy of the Overdose Kit Use Reporting form to the individual and ask them to complete it and drop it off at the pharmacy. The form is available in 2 formats:
- Online Survey – https://survey.albertahealthservices.ca/naloxone
- PDF (Paper Version) – https://www.albertahealthservices.ca/assets/healthinfo/mh/hi-amh-thn-usage-form.pdf
Completed forms can be scanned/emailed to email@example.com or Faxed to (780) 638-3844, Attn: Take Home Naloxone Kit Program.
Pharmacy Store Registration
Click here to REGISTER your pharmacy to participate in the program.
Whenever possible this form should be completed by the Pharmacy Manager. Please allow 2-3 business days for your registration to be completed. If you are not able to order kits after that time, please send an e-mail to firstname.lastname@example.org.
This program is only open to pharmacists, pharmacy technicians and pharmacy staff practicing in Alberta.
Used in emergency treatment of opioid overdose outside of hospital, naloxone is now an unscheduled drug in Alberta.
Pharmacies participating in the Community Based Naloxone program should ensure their staff are knowledgeable about the program by completing the following course.