PPE Supply Request Form

PPE Supply Request Form

for Central Texas Physicians
NEW!

We are now offering to deliver PPE to your office (if you choose).

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.
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 (for delivery): *

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 physicians/practitioners are at this location? Include any MAs, PAs, Nurses, etc., providing COVID testing *
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.

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
How many?
KN95 Masks
How many?
Patient Masks/Surgical Masks "ear loop"
How many?
Face Shields
How many?
Gowns
How many?
Coveralls
How many?
Hand sanitizer
How many?
Goggles
How many?
Bouffant Caps
How many?
Booties
How many?
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. *
Should be Empty:

PPE Supply Request Form

Supplies Requested