Give Them PPE - PPE Request Form
This form is for healthcare providers: doctors, nurses, healthcare workers, ER drivers, dentists, pharmacists...specifically for West Coast and Midwest regions.

We accept the request for small amount of supplies needed, and for bulk order (10,000 - 1M pieces).  

If you live in other regions and in dire need, please submit anyway. We can always find a way to help you.

With love and gratitude.

P.S. See our GoFundMe page here: http://gf.me/u/xsghqn

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Your Full Name *
Your Email *
Your Phone Number *
Name of Hospital / Institution You are Requesting For (Include the Department if Any) *
Full Address of the Hospital / Institution *
Street address, City, State, Zip Code
Your Job Title or Affiliation with the Hospital / Institution *
What equipment is most needed at your hospital / department? Check all that apply *
Required
Based on the equipment above, please give us specific amounts needed. Skip the ones that don't apply to you.
N95 Masks or FFP2 Equivalents
Amount
3 Ply Masks with ASTM-3
Amount
Face Shields
Amount and Model that you are using currently. Tell us your brand/model.
Isolation Gowns
Amount and Model that you are using currently (neckline, cuff, style, size?) Tell us your brand/model.
Nitrile Gloves
Amount and Model that you are using currently. Tell us your brand/model.
Swab
Amount and Model that you are using currently. Tell us your brand/model.
Other
Amount and Model that you are using currently. Tell us your brand/model.
If you are not the decision maker to get the supply, who should we contact? Please leave their email and phone number as well. *
Who should be the point person to receive the supplies? (Recipient of Package) *
If it's you, then type "me"
Approximately, how many COVID-19 patients is your hospital treating right now?
How low in supplies are you? *
Anything else we need to know? Any questions we should ask but we didn't ask? What can we help you? We have a team that can help sourcing, any specifics you need, you can send us all the details.
Thank You
Please forward this form to your co-workers, friends, who are in need of PPE. We are working and connecting with other groups of people to make this happen.

You can follow us at https://twitter.com/GiveThemPPE and https://www.instagram.com/givethemppe/ 
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