Best Care PPE Request Form

Requesting PPE

INSTRUCTIONS

Best Care Clients and Caregivers may Use this form to request a PPE kit from Best Care. There is a limit of 1 PPE kit request every 30 days per individual. (Each PPE kit contains; masks, gloves, and sanitizing wipes or sanitizer as available). Please remember in the always wear a mask, and use good hand hygene if you don't have access to gloves or sanitizer. Washing your hands with antibacterial soap is just as effectvie in preventing transmisison of covid 19.

Are you a Client or Caregiver? *

Best Care Client Best Care Caregiver

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email

example@example.com

Select Glove included with kit *

Small Medium Large Extra Large

NOTICE: PPE is provided on an as available basis. Best Care does not gaurantee PPE provided will prevent transmission of COVID-19. Prevention of any contageous disease is dependent upon proper use of PPE and hygene practices. For more information on mask use and more Covid-19 information on our website HERE.

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