Free Naloxone Kit Program

1. Enrollment
This form does not order a naloxone kit. By submitting it, you:

Request enrolment as a patient of Thornhill Drug Mart

Authorize a Part A pharmacist or other authorized pharmacy staff (interns or Part A pharmacy technicians under direct supervision) to contact you for a real-time, one-to-one counselling session.

Acknowledge that a naloxone kit will only be dispensed after that counselling session and confirmation of eligibility.

2. Eligibility

Services are available to Ontario residents who are at risk of opioid overdose, or to family members, friends or others in a position to assist them.

3. Ordering & Counselling Requirements

Ordering channels: All kit requests must be placed via telephone or videoconference, allowing real-time dialogue with a Part A pharmacist or other authorized staff. Orders via SMS, social media, apps, email, digital fax or voicemail are strictly prohibited.

Counselling: Each time a kit is supplied, you must receive a brief, individualized, real-time counselling session. Instructional videos or written materials alone are not permitted.

4. Home Delivery

Home delivery is available only if you cannot reasonably attend the pharmacy in person (due to health, mobility, distance or privacy barriers).

Delivery orders follow the same telephone/videoconference process above.

Once accepted, your kit must be handed to a delivery agent within ten (10) business days. Any unforeseen or exceptional delays must be documented promptly after the timeline expires.

5. Supply Limits

A maximum of two (2) naloxone kits per person per day may be dispensed under the ONPP.

6. Kit Specifications

All kits conform to EO Notice requirements and include:

Injectable Kit:

Zippered hard case with a “naloxone” cross

Two (2) alcohol swabs

One (1) rescue breathing barrier

One (1) pair of non-latex gloves

One (1) card identifying the person trained to administer

One (1) updated instructional insert (English & French)

Either:

Ampoule/vial format (two 1 mL ampoules or vials, same DIN) with safe ampoule openers and safety-engineered syringes; or

Pre-filled syringe format (two 1 mL 22 G/½″ needles, same DIN)

Intra‑nasal Spray Kit:

Zippered hard case with a “naloxone” cross

Two (2) doses naloxone hydrochloride intra‑nasal spray (4 mg/0.1 mL; DIN 02511568 or 02458187)

One (1) rescue breathing barrier

One (1) pair of non-latex gloves

One (1) card identifying the trained administrator

One (1) updated instructional insert (English & French)

Kit Maintenance (Recommended):

Store at room temperature, away from direct light.

Check expiry date before use. Contact us for replacement if expired or damaged.

7. No‑Cost Guarantee

Under the Ontario Naloxone Program for Pharmacies, kits and professional service fees are covered 100% by ONPP funding. There is no cost to eligible individuals unless expressly stated otherwise.

8. Anonymity & Proxy‑ID Billing

You may choose to opt out of providing personal details such as your name or date of birth. However, to process and deliver your order, you must provide a valid phone number and shipping address.

If you lack or choose not to provide an OHIP health card, you may remain anonymous using a Proxy ID:

Name: HARM REDUCTION or RESIDENT

Date of Birth: 2000‑01‑01 (or leave field empty)

You confirm consent to use the provided phone number and address solely for the purposes of counselling, order placement, and kit delivery.

9. Exclusions

The following recipients are not eligible under ONPP and will be declined:

Businesses, organisations or individuals acting on their behalf

In‑patient hospital pharmacies

Veterinary use 

10. Documentation & Record Retention

Scarborough Drug Mart Inc. collects and retains records on secure Canadian servers in accordance with PHIPA and Ontario College of Pharmacists standards:

General Records (≥ 10 years):

Patient identity (name, DOB, address, health card or Proxy ID)

Order method (telephone/videoconference)

Number and type of kits, training details, dates of service and counsellor signature

Home Delivery Addendum:

Reason for delivery

Dates: order, pickup by courier, receipt by recipient

Any exceptional/unforeseen delays documented promptly

11. Privacy & Consent

Your personal health information is collected, used and disclosed per PHIPA. You may withdraw consent at any time, subject to legal and professional obligations.

12. Professional Liability & Indemnification

We will exercise the professional skill and diligence of an Ontario‑licensed pharmacy. Except as required by law, we make no warranty of uninterrupted service or specific clinical outcomes. To the fullest extent permitted, our total liability is limited to direct damages not exceeding the wholesale replacement cost of one kit. You agree to indemnify us against losses from inaccurate information, missed counselling, misuse or unauthorized redistribution of kits.

13. Emergency Disclaimer

Naloxone provides temporary reversal of opioid toxicity and is not a substitute for emergency medical care. Always call 911 first if you suspect an overdose.

14. Governing Law & Dispute Resolution

These terms are governed by the laws of Ontario and Canada. Any dispute shall be submitted to the exclusive jurisdiction of Ontario courts.

15. Contact Information

Thornhill Drug Mart

8108 Yonge St Unit 3-4, Thornhill, ON L4J 1W4
Phone: (905) 709-9985  |  Pharmacy Manager: Mandana Kardar
Email: [email protected]

16. Acceptance of Terms

By clicking “Submit,” you confirm that you:

Reside in Ontario and meet ONPP eligibility;

Understand this form enrolls you in EndOverdose’ pharmacy program and initiates a callback;

Consent to collection, use and disclosure of your personal health information as described;

Verify that you are unable to reasonably attend the pharmacy in person due to health, mobility, distance or privacy barriers (if requesting home delivery);

Agree to indemnify Thornhill Drug Mart., its pharmacists and staff against any claims, losses or liabilities arising from any misrepresentation of your eligibility, missed counselling sessions, misuse, or unauthorized redistribution of kits;

Accept all terms, conditions, limitations and obligations set out above.