Medical Equipment Request Form
By filling out this form, you agree to allow MasksforIndia to disclose the information you provide to MasksforIndia , consistent with MasksforIndia's mission to connect personal protective equipment (PPE) suppliers to those who need it most--the healthcare providers at the frontline.
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Purchasing Contact Name
Purchasing Contact Email
Purchasing Contact Phone
Type of Organisation
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Product Type *
Quantity Required(for each product) *
Number of beds(at your institution)
Address
State
Zip Code
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