Hospital Distribution Request

We are currently manufacturing goods for NYC COVID-19 Emergency Services, LLC (NYCCES), in coordination with the New York City Economic Development Corporation (NYCEDC), to ensure that Spiro Waves are distributed to hospitals in NYC. NYC hospital information will be shared with NYCCES/NYCEDC, who will follow up directly with regards to requests for orders they are able to fill.

We are also collecting hospital need information for other areas, which may be shared with government agencies in order to inform distribution efforts as we scale.

Contact Information

Name*

First NameLast Name

Title*

Email*

Work Phone*

Mobile Phone

Medical Facility Information

Facility Name*

Facility Location*

Address Line 1

Address Line 2

CityState

Are you a New York City-based hospital?*

YesNo

Hospitals and healthcare facilities with a demonstrated need for additional ventilator units to address the COVID-19 outbreak in New York City may be eligible to purchase units from NYC COVID-19 Emergency Services, LLC (NYCCES), in coordination with the New York City Economic Development Corporation (NYCEDC). The information collected in this order form will be provided to NYCCES/NYCEDC for their consideration and use.

NYCCES has a limited number of available Spiro Waves that were purchased from Spiro, and they may not be able to fill all orders received or accommodate all terms requested in this order form. NYCCES reserves the right to change any terms, negotiate alternate pricing or delivery structures, or refuses to fill some or all of any order requested. If NYCCES is able to fill an order, it will provide the applicant with a purchase order, and the order will not be finalized until receipt by NYCCES of the executed purchase order and any required payments.

Receiving Contact

Receiving Contact Name*

Receiving Contact Email*

Receiving Contact Phone*

Receiving Address

Receiving Company

Attention*

Destination Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Request Information

Requested Quantity*

Requested Delivery Date*

MM-DD-YYYY

Shipping Requirements

(If any, e.g., standard pallets, 70-gauge stretchwrap, labeling details)

Calibration Information

Proper operation of the machine requires calibration against your organization’s existing BVM(s). Complete the section below to ensure your machines are calibrated accordingly.

Bag Valve Mask (BVM) Manufacturer*

BVM Model #*

BVM Size(s)

If Applicable

Please verify that you are a human*

This form is subject to our Terms & Conditions and Privacy Policy. Your submission of this form is just a non-binding request for information, and does not constitute or create any obligation upon us. We are doing our best in light of the current pandemic, so please understand that we cannot guarantee the timing for any response.

Please agree to these terms to proceed.*

Yes, I agree to the above terms and conditions.