UAC PPE Request Form

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We are United Against Covid-19 (UAC), an alliance composed of healthcare professionals, psychotherapists, social workers, donors, and volunteers. Many experts believe the pandemic response and medical situation in the United States is deteriorating.

At UAC, our mission is to unite everyone’s individual power and, together, win this struggle against COVID-19.

The purpose of this form is to help those who are in an urgent need for PPEs to save lives. Please fill out as much of this form as possible so that we can properly handle your request. The submission of this form goes to a password-protected Google spreadsheet.

If you are willing to donate money for our purchase of PPEs, please visit our fund raising campaign at gf.me/u/xxkga3. It will be greatly appreciated.

Please note that UAC is a small-scale group and we have been working hard to offer PPEs that are qualified and legitimate. UAC has no affiliation to any PPE suppliers or their products as it is run by unpaid volunteers trying to help however they can.

We will reach out to you once we find a match to your request(s).

Your Name *

Your email address *

Your phone number *

US phone number in one of the following formats with or without extension: (123) 456-7890x12345, 123-456-7890x12345

Name of the hospital/organization you belong to *

City/State of the entity in previous question *

Select Healthcare or Public setting this donation goes to *

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