Registration - Harm Reduction Therapeutics

Please register for a customer account

RiVive™ OTC (naloxone HCl nasal spray 3 mg) is available for 501(c)(3), 501(c)(4), 501(a) organizations to purchase to help save lives that would have otherwise been lost due to opioid overdose.

Organizations are subject to approval by Harm Reduction Therapeutics and include, but are not limited to, Community Treatment Centers, EMS, Fire Departments, Public Safety Departments, Federal and State Government Agencies and other harm reduction organizations.

STEP 1 of 2: Create an account

Please complete the following information and submit for approval

(* denotes mandatory field)

* Full Name

* Email Address

* Phone Number (numbers only)

* Create a Password

(Password must be a minimum 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 Copy of your non-profit certificate (1023-EZ, 1023 or 1024)

The Approximate Number of People Serviced

* 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™ OTC (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™ OTC (naloxone HCl nasal spray 3 mg)

* I agree

* I have read and agree to the privacy policy

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™ OTC (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

RiVive^™ OTC Account Registration

Please register for a customer account

STEP 1 of 2: Create an account

Please complete the following information and submit for approval

STEP 2 of 2

Tell us about your organization

Thank you

Sign Up

Thank you

RiVive™ OTC Account Registration

Please register for a customer account

STEP 1 of 2: Create an account

Please complete the following information and submit for approval

STEP 2 of 2

Tell us about your organization

Billing Address

Thank you

Sign Up

Thank you

RiVive^™ OTC Account Registration