JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Artisan's Asylum Support Intake
Artisan's Asylum is providing PPE at cost to institutions. We do not supply the public. We currently have disposable and reusable face shields and isolation gowns. We are developing surgical face masks and hair nets.
Depending on the needs of your medical group, we may be able to accommodate large-scale orders ranging from hundreds to thousands. All of our designs are based on approved open source models in use.
Please complete this form if we might be of service to you and your staff. Thank you for all that you are doing to keep our communities safe and prevent the spread of COVID.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Organization/facility
*
Your answer
Contact Name
Your answer
Contact Title
Your answer
Contact Phone Number
Your answer
Contact Delivery Address
Your answer
What supplies are needed
Disposable face shield
Reusable face shield
Disposable surgical mask
Reusable face mask
Medical gown
Hair net
Other:
As a community based non-profit, we need to understand our costs and potential losses. What is the approximate price acceptable to pay (for example: Shield, $4.0, Mask $0.50, Gown $7.50)?
Your answer
How many of each item do you use per day? How many are you receiving from existing supply chains?
Your answer
How long do you expect your current stock to last, without a new supplier?
Your answer
Can you provide us with your required production cleanliness standards? This tells us what to make for you.
Your answer
Anything else we should know about working with your organization?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Artisan's Asylum.
Report Abuse
Forms
