Shallowater Home Oxygen Use Registration Form
This registration form is for individuals who reside in the City Limits of Shallowater who receive home oxygen.  Registering your information will allow the City of Shallowater Office of Emergency Management to assist you, if necessary, during power outages or other incidents to make sure that you have an adequate supply of home oxygen during situations that may cause you to not be able to use your Oxygen Concentrator or portable machine.  This information allows us to make contact with you and assist you in taking care of your home oxygen needs until the power is restored or the incident is mitigated.
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What is your FIRST name? *
What is your LAST name? *
Do you live inside the Shallowater City Limits? *
What is your physical address? No P.O. Boxes. *
What is a phone number that you can be reached at? (Format: 888-888-8888) *
Do you have anyone to assist you during a situation where your Oxygen Concentrator does not work? *
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