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Please fill out this form to request Narcan kits, Fentanyl test strips, or Xylazine test strips. All information provided will be kept confidential.

Personal Information
* Full Name (First name, Last name)
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* Phone Number and Email (702-234-1567, vegas123@yahoo.com).
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* Delivery Adress (1234 S Main Street, Apt 21, Las Vegas, NV 89120)
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* Preferred Delivery Time?

Materials Requested
* Please select the materials you need:
* How many Narcan kits do you need?
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* How many Fentanyl Test Strips do you need?
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* How many Xylazine Test Strips do you need?
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* Reason for Request?
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Training Needs
* Do you need instructions on how to use the requested materials?
* If yes, select preferred method(s)
* Affiliation (if any with partner organizations).
0/250

Consent for Follow-Up
* May we contact you for follow-up support or feedback?

Signature & Date
* Enter your First and Last Name
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* Date (04/30/2024)
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UNI Cares Project | 2375 E Tropicana Ave Suite 8 PMB 153 | Las Vegas, NV 89119 US

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