Surgical Mask Distribution Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The Town of Pantego has acquired surgical masks from Tarrant County. While these masks aren't the N95 masks, they still do offer a layer of protection. We will distribute these as quickly as possible to residents and businesses who need them. While we may not be able to fully meet every need, masks will be distributed as equally and as fairly as possible until supply is depleted.

Email *

****all information gathered as part of this process will be kept confidential and shared only with essential members of the Town****

Name of Person Filling Out This Form *

Phone Number Person Filling Out This Form *

Is this for residents or business? *

Residents

Business

NAME of Family / Business Needing Masks *

Primary PHONE Number *

ADDRESS of Family / Business Needing Masks *

Is any member of this residence considered high risk for COIVD19? *

Yes. One or more of the following: respiratory history, elderly, immunocompromised

unknown

N/A

What is the IDEAL NUMBER OF SURGICAL MASKS we can provide you? *

We have the ability to deliver your masks. Do you need delivery? *

I can pick them up

I need them delivered

What other COVID-19 needs we can help your family or business with? Shopping assistance, etc. (please include detail)

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms