PPE Order Form
Please use this form to inform Focus Care of which PPE you need delivered.
Name
*
First Name
Last Name
Confirmation of Postal Address
*
Street Address
Street Address Line 2
Suburb
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
Which PPE items would you like to request?
Gloves (box of 100 pieces)
Face Masks (box of 50 pieces)
Showering Apron - Standard (10 aprons)
Showering Apron - Long (10 aprons)
Arm Covers (10 pairs)
Shoe Covers (10 pairs)
Hand Sanitiser (60ml)
Which glove size do you require?
Small
Medium
Large
Extra Large
How many hand sanitisers do you require?
Please Select
1
2
3
4
5
How would you like to receive your PPE?
Pick up from Head Office (please state date and time in comment box below)
Posted to my house
Do you have any additional requests or comments?
Submit
Should be Empty: