PPE Supply Request Form

We are requesting PPE from the state. We cannot guarantee quantities or availability for items. If there is a delay, or out of stock items, we will notify you before your scheduled pickup time.

If you have multiple locations, please complete a form for each location.

After you submit your order, we will send an email confirming receipt along with additional information for supply pick up.

Your Name *

First Name Last Name

Title (ex: Office Manager, Physician) *

Practice Name *

Preferred Phone Number *

Area Code Phone Number

Preferred Email *

example@example.com

Primary Specialty *

Practice Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Would you like the PPE delivered or will you pick up? A confirmation email will be sent with additional information. Note: we are unable to deliver to home addresses. *

Please deliver to the address above Someone from my office will pick up

How many practitioners are at this location? *

Are you seeing patients with upper respiratory symptoms or persons of interest? *

Yes No

Are you performing nasopharyngeal swabbing for COVID-19 testing? *

Yes No

Are you performing aerosolizing procedures? *

Yes No

We are continuously receiving supplies.

Please indicate how many items you need for 1 day and we will do our best to provide enough for 1-2 weeks.

Four N95 masks will be provided for each practitioner so that you can reuse them as outlined in the best practices section below.

Small Gloves (box of 100)

How many?

Medium Gloves (box of 100)

How many?

Large Gloves (box of 100)

How many?

X-Large Gloves (box of 100)

How many?

N-95 Masks (Teal, straps go over the head, box of 20)

How many?

KN95 Masks (white, ear loop, box of 50)

How many?

Patient Masks ("ear loop" non-medical)

How many?

Surgical Masks ("ear loop" medical)

How many?

Face Shields

How many?

Gowns

How many?

Coveralls

How many?

Gel hand sanitizer (Boxes of 12 - 8oz bottles)

How many?

Goggles

How many?

Bouffant Caps

How many?

Booties

How many?

Patient Gowns (box of 50)

How many?

When will you be picking up your PPE?

August 24, 12:00pm to 4:00pm August 29, 12:00pm to 4:00pm August 31, 12:00pm to 4:00pm

Other Comments or request:

Office Hours (days of the week and times you are available to accept delivery). If you will be picking up, just put "pick up" in the box. *

PPE Supply Request Form

Supplies Requested