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Medical Facility Request Form
Thank you for choosing to provide support to those who are experiencing pregnancy and infant loss. Please use the below form to request items for your clinic or hospital.
If you have any questions about any of our items please email Danielle@lovingtanner.com
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Today's date
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Clinic or Hospital Name
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Your answer
Contact email for any questions about this request.
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Your answer
Which items are you requesting?
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Love & Loss Care Boxes (for 2nd & 3rd trimester losses and infant loss up to one year) these are generally provided to labor and delivery units or OB units for followup if the parents do not receive a box following delivery
Forget-Me-Not Boxes (for miscarriage and early term loss up to 12 weeks) these are generally provided to OB clinics, family practice clinics and Emergency Departments
Memory Making Kits (air dry mold, rolling pin, ink pads) for healthcare staff to create hand & foot molds and prints of baby
Required
How many of each item would you like?
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Your answer
Please choose how you would like to receive your items (local drop off timeframe is based on the availability of our volunteers)
Local Drop Off (For locations in Cedar Rapids, Waterloo, Independence, Manchester areas)
Local Pick Up (From our Winthrop Office Location) We will contact you to arrange pick up
Please ship to us at the address provided below
Other:
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Shipping Address (include city, state and zip code)
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For Local Drop Off Please Provide the Floor, clinic area etc to leave items and a name to put on the items
Your answer
For Local Pick Up Please send an email to info@lovingtanner.com to arrange day and time.
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