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Forth Valley Home Delivery Information Form

Orders placed before 1pm will qualify for next day delivery.

Please remember in addition to the equipment charge there will be a delivery charge of £8.00.

Fields marked with an * are required

Intro Statement

Mandatory Introduction Statement: I'll take your order and double-check your name, address and phone number so we know it's going to the right place. Then I'll email it over to our supplier, who will use your details to put together your order and get it posted out to you. They'll delete your data afterwards. We will need you to be available when the parcel is delivered, so make sure you're in at the time that's texted or emailed to you. Just like our normal needle exchange, we (do/) don't keep a record of your order (with your file on our secure database). If you have any questions that I can't answer, I can give you a link to our web privacy notice or you can email ForthValley.Admin@cgl.org.uk.

Please tick to confirm above statement delivered to client *

Please provide client name for order to be sent to *

Please provide an address where client will be in to receive the delivery socially distanced (note: cannot be left without recipient being present) *

Please Provide Postcode *

Mobile Number client is contactable on to arrange delivery *

Email address client is contactable on to arrange delivery (optional)

Has client used NSP either in pharmacy or with us before? We ask so we can explain how it works and help tailor our advice to the client *

Is client ordering for themselves only, themselves and others or others? (This is so we can see how many people we are supporting) *

How are they today? Any infections or sores at injecting sites? (If Yes, please signpost for advice from nurse or local pharmacist etc) *

What substance are they primarily injecting? *

Where in the body are they injecting? *

Does the client have Naloxone? If not this can be provided but please provide training over phone. ( DQ227 Naloxone Policy and Paperwork https://docs.google.com/document/d/1B-LqC51GBhMtSdTYRYR2pJZxj0aD8J3K4wSF7G3rndA/edit?usp=share_link) *

Number of Naloxone kits required *

Please confirm with client order details and advise they will receive a text or email from the courier to confirm their order is received and advise of delivery time and date *

Divider

Name of Service placing order? *

Name of Staff Placing Order (Full Name Please) *

Email address for a copy of the order to go to (optional)

Do you require notification of a 1 hour window? If yes, provide your email or mobile number.

If only a small order is placed discuss whether recovery worker can deliver it instead. But under no circumstances must the delivery be sent by post, in accordance with organisational policy

If you are unsure about the suitability of equipment or advice to provide please seek advice from a more experienced harm reduction worker or ring the office

Need help or advice? Call 01869 325912

Forth Valley Home Delivery Information Form