Partners for World Health · Medical Facility Requests for COVID-19 Supplies

Thank you for reaching out to Partners for World Health to fulfill your request for medical supplies in response to COVID-19. Please use this form to request the PPE and other supplies/ equipment your facility is in need of. The PWH Medical Supply Program will do our best to meet these needs. This will help us serve you more effectively and efficiently! Someone will contact you regarding your request within 3-5 business days.

Contact Information

Name

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First Name

Last Name

Email

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Verify Email

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Phone

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Medical Facility Receiving Supplies:

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Medical Facility Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Medical Professional Responsible:

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Please describe your request (items needed, quantity, sizes, etc)

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Date Supplies are Needed

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(mm/dd/yyyy)

Required Affirmation:

The individual completing this form guarentees that the supplies received 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.*

I understand and agree to the above statement:

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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.

Release of Liability

I have read and agree to the release of liability:

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Additional Comments: