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Medical Supply Request - Domestic
Thank you for reaching out to Partners for World Health to fulfill your request for medical supplies. The PWH Medical Supply Program provides a wide range of medical supplies, machines and equipment to an individual or organizations in exchange for a financial donation. Your contribution helps us offset the expenses associated with collecting, sorting and storing the supplies. The Medical Supply Program is a service to support our domestic and international partners. Please take a few moments to complete this form. This will help us serve you more effectively and efficiently! Someone will contact you regarding your request within 3-5 business days.
Contact Information

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If you have not done so already, please email a copy of your Maine State Sales Tax-Exempt certificate to medicalsupplies@partnersforworldhealth.org

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Required Affirmations

The individual completing this form guarentees that the supplies I receive from Partners for World Health, will be administered by the medical professional listed above or by others under his direction for the benefit of those served by the institution above. I understand that these supplies are donated and as such have no commercial value and that the items are not to be sold, resold, or exchanged for profit or gain. I further attest that I have read and agree to receive donated items from Partners for World Health according to the pre-disclosed stipulations.*

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Please read the Release of Liability liked below, it will open in a new window. Please confirm that you have read the document completely and agree with all of the conditions stated in it. Please print this form, sign it and bring to your appointment. Thank you.

https://68baeb24-d592-412d-b702-14b7e1dca8e0.usrfiles.com/ugd/68baeb_73c45814cc3f45c7af325df0b39873f2.pdf

 

 

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