Naloxone by Mail Request Form

If you live in Jackson, Josephine or Klamath County, fill out the form below and we will mail you a life-saving Naloxone kit. All personal information gathered in this form is strictly private and never shared outside of Max's Mission Naloxone by Mail program.

First name

Last name

Date of Birth

Month

Day

Year

(Demographic information helps us better understand who we’re reaching, where the greatest needs are, and how we can improve our efforts to best provide life-saving resources in Jackson, Josephine and Klamath communities.)

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Have you received naloxone from Max's Mission before?

Yes

No

If yes, was the naloxone used to reverse an overdose?

Yes

No

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