Request a Free Grocery Delivery
Here is the form to request a grocery delivery. We will usually fulfill your order within 1-2 days. If you would like to send us pictures of the items, do so at pdxconcierge2020@gmail.com or 971-347-7778. Tips are optional. Thank You!
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Phone Number? (cell preferred, please specify if it's a landline) *
What is your grocery list? (including the store). Please be as detailed as you can, and if possible, separate each item with a carriage return (a new line) *
Do You Have a Preference for the Date? (EXAMPLE: I would like the delivery done BY________ or I would like the delivery done ON__________ *
Home Address *
How did you hear about us?
What is your birthday? (optional)
MM
/
DD
/
YYYY
Have you or your family tested positive for COVID-19?
Clear selection
Acknowledgement: PDX Concierge is volunteer-based service and intends to help the community. We hold your private information in high regard and will maintain confidentiality. We are not legally liable for any spoiled foods, incorrect items, or similar concerns and have the permission to provide our volunteers with your personal information to deliver groceries. If there are incorrect items, we will try to get a refund. We also expect you to comply with local and CDC guidelines when receiving delivery at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy