Empower And Excel---Physicians Support Group (PSG)--PPE Donation Form

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This initiative is led by a passionate group of physicians solely to meet the needs of PPE for healthcare professionals in collaboration with E&E during COVID-19.
We are in the process of procuring FDA approved N95 masks and other PPE/supplies to help protect our front-line heath care providers.
If you would like to donate PPE items, please fill out this form and we will get back to you by this Saturday.
We appreciate your support!
Empower and Excel PSG volunteers

Email *

Name (First, MI, Last) *

Items to be Donated *

N95 Masks

Surgical Masks

Face Shields

Other:

Phone Number *

Your Profession *

Address *

Drop Off or Pick Up? *

Drop off at our location

Pick up from your location

Best Way to Contact You *

Phone

How did you hear about us?

friends/families

Facebook

Other:

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