I Want To Donate
This form is for the sole purpose of making sure that patients and caregivers get the supplies they need. The #HarveyPatients campaign was started by health advocates; Brooke Abbott, Alison Rothbaum, & Molly Schreiber. These three advocates have been behind successful Twitter campaigns for patients rights and are constantly working toward making sure that patients living with chronic conditions have a better quality of life. Brooke, was a resident of San Antonio and currently has family living in Southeast Texas. All of Brooke's Texas based family have been affected by Hurricane Harvey. Helping patients get through the Harvey aftermath is top priority for these advocates.

Medical supplies, clothes, diapers, and whatever else you would like to donate is welcomed! Please make sure that they are packed in a way that water cannot penetrate items. Please indicate what is new and what is used so we can sort accordingly. Once you turn in your form, we will send over the address and the items we can accept. Thank you again!

This form is confidential. It will stay in records only seen by Brooke, Alison, & Molly who will dispatch deliveries to patients or coordinate pick ups at local shelters.

**PLEASE NOTE** This is not intended to provide immediate, emergency assistance. Please contact your local authorities if you need help right away.

Full name (please include last name)
Your answer
Email
Your answer
Phone number
Your answer
Location (include City & State)
Your answer
Shipping or Drop Off
Adult Clothes (Description & Sizes)
Your answer
Used or New
Kid Clothes (Description & Sizes)
Your answer
Used or New
Medical Supplies
Your answer
Used or New
Medication (Describe & Amount)
Your answer
Food (Describe & Amount)
Your answer
Toiletries (Describe & Amount)
Your answer
Bedding & Bath Towels (Amount)
Your answer
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