PPE Supply Request Form

PPE Supply Request Form

for Central Texas Physicians
In order to prevent duplicate requests, only one form per group/practice should be submitted. If your group has multiple locations, please provide information for a central location where the PPE will be housed. You will be responsible for picking up and distributing the PPE to all locations.
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
What is your specialty? *
Practice Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How many physicians/practitioners are in your practice? *
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
Supplies Requested
We are continuously receiving supplies, so please order only 1 week's supply. 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
How many?
Surgical Masks (currently unavailable)
How many?
Patient Masks
How many?
Face Shields
How many?
Gown (surgical, sterile)
How many?
Coveralls
How many?
Hand sanitizer
How many?
Other Comments or request:
Best Practices

N95 masks:

It is important that your mask has time to dry out after use. One method is placing your mask in a paper (not plastic) bag at the end of the day. Write the date on the bag. Use it again after 3 days.

It is also important to have the mask “fit-tested” to assure a good seal on your face.

Another tip is to use a standard surgical mask or a home-made mask over your N95 to protect it from splashes and gross contamination.

Hand Sanitizer:

Most of the hand sanitizer that has been donated is in large containers. consider keeping your smaller containers and refilling them.
Should be Empty:

PPE Supply Request Form

Supplies Requested