Naloxone & Harm Reduction Supply Order Form InstructionsAll orders are to be submitted to Lambton Public Health by the 10th of the month or the business day prior to. Once the order arrives, you will be contacted to arrange for pick up at Lambton Public Health, 160 Exmouth Street, Sarnia. Thank you.Organization Placing Order(Required) Lambton Public Health Lambton Public Health- Outreach North Lambton CHC Aamjiwnaang Health Centre Kettle and Stony Point Mental Health & Wellness Hub Walpole Island Health Centre John Howard Society Sarnia-Lambton Bluewater Health CMHA Grand Bend Community Health Centre CHIC Kettle & Stony Point Health Services Social Services Outreach HHRC Naloxone Organization Contact InformationContact Name(Required)Email(Required) PhonePhone Ext. (If applicable)NaloxoneOrder QuantityNaloxone – Nasal (Current Inventory)Please enter a number greater than or equal to 0.(60 per case) Naloxone – Nasal (Order Quantity)Please enter a number greater than or equal to 0.(60 per case) Naloxone – Injection (Current Inventory)Please enter a number greater than or equal to 0.Injection (Order Quantity)Please enter a number greater than or equal to 0.Swabs & WipesOrder QuantityAlcohol Swabs (Order Quantity)Please enter a number greater than or equal to 0.(4,000 per case)Castile Wipes (Order Quantity)Please enter a number greater than or equal to 0.(2,000 per case) (Replacing BKZ Wipes)Injecting SuppliesOrder QuantityFilters Blister Packs (Order Quantity)Please enter a number greater than or equal to 0.(500 per box)Sterile Water (Order Quantity)Please enter a number greater than or equal to 0.(1,000 per case)Tourniquets (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)Vitamin C (Order Quantity)Please enter a number greater than or equal to 0.(1,000 per box)Cookers – One-Use (Order Quantity)Please enter a number greater than or equal to 0.(3ml) (1,000 per box)Cookers – Stericup (Order Quantity)Please enter a number greater than or equal to 0.(3ml) (1,000 per box)Cookers – Maxicup (Order Quantity)Please enter a number greater than or equal to 0.(5ml) (1,000 per box)Long Syringes (Order Quantity)Please enter a number greater than or equal to 0.1ml insulin 28g x 1/2″ (500 per case)Short Syringes (Order Quantity)Please enter a number greater than or equal to 0.1ml ultrafine insulin 30g x 5/16″ (500 per case)Tips – 22G 1½" (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)Tips – 23G 1" (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)Tips – 23G 1½ " (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)Tips – 25G 5/8" (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)Tips – 25G 1" (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)Tips – 27g 1/2" (Order Quantity)Please enter a number greater than or equal to 0.(100 per box)New Tips – 18g x 1 1/2" tips (Order Quantity)Please enter a number greater than or equal to 0.18g x 1 1/2″ tips (100/box)BagsOrder QuantityBlack Baggies Ties Closed (Order Quantity)Please enter a number greater than or equal to 0.(ties closed) (1,000 per box)Blue Baggies Ties Closed (Order Quantity)Please enter a number greater than or equal to 0.(ties closed) (1,000 per box)Green Baggies Ties Closed (Order Quantity)Please enter a number greater than or equal to 0.(ties closed)(1,000 per box)Yellow Baggies Ties Closed (Order Quantity)Please enter a number greater than or equal to 0.(ties closed)(1,000 per box)Clear Baggies Zipper Sealed (Order Quantity)Please enter a number greater than or equal to 0.(zipper seal) (100 per pack)Blue Baggies Zipper Sealed (Order Quantity)Please enter a number greater than or equal to 0.(zipper seal) (100 per pack)Green Baggies Zipper Sealed (Order Quantity)Please enter a number greater than or equal to 0.(zipper seal) (100 per pack)Orange Baggies Zipper Sealed (Order Quantity)Please enter a number greater than or equal to 0.(zipper seal) (100 per pack)Black Baggies Zipper Sealed (Order Quantity)Please enter a number greater than or equal to 0.(zipper seal) (100 per pack)Inhalation SuppliesOrder QuantityStraight Stems (Order Quantity)Please enter a number greater than or equal to 0.(1,320 per case)Tubing Stems (Order Quantity)Please enter a number greater than or equal to 0.(100 ft. Roll)Pre-Cut Mouthpieces Stems (Order Quantity)Please enter a number greater than or equal to 0.(100 per pack)Bowl Pipes (Order Quantity)Please enter a number greater than or equal to 0.(432 per case)Tubing Bowl (Order Quantity)Please enter a number greater than or equal to 0.(100 ft. Roll)Pre-Cut Mouthpieces (bowl pipes) (Order Quantity)Please enter a number greater than or equal to 0.(100 per pack)Push Sticks (Order Quantity)Please enter a number greater than or equal to 0.(144 per box)Screens – IMPACT 1.0 blue (Order Quantity)Please enter a number greater than or equal to 0.(100 pks per box)Screens – IMPACT 2.0 Orange (Order Quantity)Please enter a number greater than or equal to 0.(100 pks per box)Foils & StrawsOrder QuantityFoil (Quantity Ordered)Please enter a number greater than or equal to 0.30 packs of 24 per box (720 per box)Blue Straws (Quantity Ordered)Please enter a number greater than or equal to 0.(250 per pack)Yellow Straws (Quantity Ordered)Please enter a number greater than or equal to 0.(250 per pack)Green Straws (Quantity Ordered)Please enter a number greater than or equal to 0.(250 per pack)Orange Straws (Quantity Ordered)Please enter a number greater than or equal to 0.(250 per pack)CondomsOrder QuantityLatex Condoms (Quantity Ordered)Please enter a number greater than or equal to 0.(1,000 per case)Flavoured Condoms (Quantity Ordered)Please enter a number greater than or equal to 0.(1,000 per case)Lube (Quantity Ordered)Please enter a number greater than or equal to 0.(1,000 per case)Sharps Disposal BinsOrder QuantityLarge Sharps (Quantity Ordered)Please enter a number greater than or equal to 0.4.8L (32 per case)Medium Sharps (Quantity Ordered)Please enter a number greater than or equal to 0. 1.4L (36 per case)Additional Information / CommentsQuestions or Comments: