Standing Order Participation
If you are representing a pharmacy in North Carolina (N.C.) that plans to dispense naloxone to patients in N.C. under the State Health Director’s standing order for naloxone, we ask that you please provide the information below to the N.C. Department of Health and Human Services, Division of Public Health’s Injury and Violence Prevention Branch. While providing this information is not a prerequisite to your pharmacy being able to dispense naloxone under the standing order, the Division of Public Health would like to know which pharmacies are using the State Health Director’s standing order.
This information will be used to count and map locations of pharmacies that are increasing access to naloxone to people in N.C. under this standing order and will be publicly shared with those seeking to obtain a prescription for naloxone in order to direct them to your business.
Please submit this form multiple times if you are signing up multiple pharmacy locations. If you wish to sign up more than three pharmacy locations at the same time, you may send an email to firstname.lastname@example.org or sign up multiple participating locations at the same time by downloading this spreadsheet.
Thank you for your time and being a part of saving North Carolinian lives. Please email email@example.com with any questions or comments.