Vermont Naloxone Record

Please complete the form below for each adminstration of naloxone you provided in Vermont. For location, enter either ther city and state or the postal code (if both are not available).

Date Administered

Time

Hours

Minutes

AM/PMAMPM

City

State/Province

ZIP / Postal Code

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Dosage form administeredNasal SprayInjection

Amount of medciation administered

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