Chicago PPE Hospital and Medical Order Request

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We supply three-layer 99% BPE melt-blown surgical-style masks in large quantities with short lead times to hospitals, assisted living facilities, COVID-19 crisis command centers. We are also making items available to support businesses and health care provides. Fill out this form to tell us about your needs and we will contact you as soon as possible.

Email *

Disposable mask with elastic ear loops. 6 3/4 x 5 inches fully extended:

How many masks do you need? How frequently?

One Time

Per Month

Per Week

Other

50 to 1,000

2,500 to 10,000

100,000 to 500,000

1 million or more

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What information will you need before placing an order?

Product Sample

Company Information

FDA or CE Certifications

Tax ID Number

Pricing

Other:

What authorization do you have to place an order?

I have the authority and the budget to place an order immediately.

I need approval from by direct boss.

I need approval from a committee.

We need to obtain clearance for a special order.

Other:

What other questions or comments do you have?

Your Name *

Your Title

Organization

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Best Phone number *

Can we text this number? *

Yes

What time zone are you in? When is the best time of day to call you? Can we call you in the evening or on weekends?

A copy of your responses will be emailed to the address you provided.

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