Donation Form- Medshare- Laurel's Version

Supplies & Equipment Donation Form
Contact Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Where is your Donation Located?*

Street Address

Street Address Line 2

CityState

Zip Code
Your Donor Type*

IndividualPhysicians PracticeHospital / ClinicCorporationNon-Profit / NGO
Name of Organization/ Affiliation*
Do you have a Deadline Date to ship the items from your location?*

YesNo
Enter your Preferred Deadline Date at least 3 weeks from today. We will attempt to meet your preference where possible but it is not guaranteed.

MonthDayYear
Date
DONATION OFFERS
Donation Type (select one or both then enter the details below)*

Medical Supplies (gloves, syringes, dressing etc.)Medical Equipment (monitors, scales, PCR machines etc.)
Current Date

MonthDayYear
Date
Expiry Date

MonthDayYear
Date
Please be aware that we are only able to accept items with Expiration dates that are AFTER {expiryDate} . Look for the following symbol on the item's packaging:

If there is no expiration date on the packaging, leave that field blank.
For Medical Supplies:
Alternatively, you can upload an Excel file with the same information above:

Cancelof
For Medical Equipment :
Upload photo(s) of Medical Equipment Condition / Parts / Manuals

* Photos are not needed for medical supplies
Cancelof
Additional Comments (as needed)
i.e. "need to schedule delivery date, please contact"
Should be Empty:

Supplies & Equipment Donation Form