OTC RiVive^® Account Registration

Before you begin the registration process, please be sure to have a digital copy of your Non-Profit Certificate or Tax Exempt Form containing your tax-exempt ID number on hand. You will be required to upload one of these two documents in order to complete your registration.

If you have questions or if you need any assistance with this form, please Email sales@harmreductiontherapeutics.org or call (888) 412-7454

Please complete the following information and submit for approval

Full Name *

Email Address *

Phone Number (numbers only) *

Create a Password *

(Password must be a minimum of 12 characters: a combination of uppercase letters, lowercase letters, numbers and at least 1 symbol)

Re-enter Password *

Organization Name *

Organization Type *

City/County *

Please Provide Details *

Tax Exempt ID Number *

Tax Registration Name *

Jurisdiction of Registration *

Upload a copy of your Non-Profit Certificate or Tax Exempt Form (1023-EZ, 1023 or 1024)*

The Approximate Number of People Serviced Annually

Planned method of purchase *

Purchase Order

Online via Credit Card

Both

Billing Address

Address

City

State

Zip Code

Purchase Frequency *

One Time Purchase

Expected recurring orders

Customers may not:

Resell RiVive (naloxone HCl nasal spray 3 mg) for profit nor at a price higher than what you paid.
Bill health insurance.
Charge a fee to end-users for receipt of RiVive (naloxone HCl nasal spray 3 mg).

I agree *

I have read and agree to the privacy policy*

* denotes mandatory field

Sign Up

Name

Email Address

Phone Number

Password

Confirm Password

Name

Type

City/County

Please provide details

Tax Exempt ID number/ status

Upload of photo/PDF of document (1023-EZ, 1023, or 1024)*

Approx number of people serviced

Purchase Frequency *

One Time Purchase

Expected Re-occurring Orders

I May not:

Resell RiVive™ (naloxone HCl nasal spray 3 mg) for profit nor at a price higher than what you paid
Bill Health Insurance
Charge a fee to end-users for receipt of RiVive

I have read and agree to the privacy policy

OTC RiVive® Account Registration

Before you begin the registration process, please be sure to have a digital copy of your Non-Profit Certificate or Tax Exempt Form containing your tax-exempt ID number on hand. You will be required to upload one of these two documents in order to complete your registration.

Billing Address

Thank you

Sign Up

Thank you

OTC RiVive^® Account Registration