GogglesForDocs Request Form
A few reminders to all interested hospitals:
--Dark lenses are being deployed outdoors. Light lenses indoors.
--Hospitals and departments who are accepting used goggles are doing their own disinfection. Used goggles arrive in a variety of packaging.
--New goggles are packaged.
--It seems that a hospital or departments willingness to accept various goggle types are directly correlated to the intensity of COVID-19 in their population.
--Goggles will need to be sanitized by your team upon receipt.
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With donations decreasing in recent weeks, new requests are welcome but are unlikely to be fulfilled. Please also note that we are no longer fulfilling requests outside of US and Canada.
Organization *
Department *
Your Name *
Your Title *
If you are not part of hospital/clinic leadership, please note that we will need approval from the leadership team before we can process your request
Your Phone Number *
Please use XXX-XXX-XXXX format.
Phone Number for the Donation Form *
Some services like FedEx require a phone number to ship packages. This will be listed on our donation form.
Your Email Address *
Mailing Address *
Where should the goggles be shipped?
Type of Address *
City *
State *
Zip Code *
Country *
Receivers's Name *
Name of the person who will receive shipments of goggles.
Drop Off Spot *
If goggles are dropped off in person, what would be the most appropriate and safe location to do so?
Number of Goggles Needed *
New or Used Goggles? *
Would you be open to receiving jockey-style goggles? *
An example of what these look like: https://www.ridertack.com/sorz-goggle-p/twszsrgg.htm
Additional Details *
Please elaborate on your work environment. For example, are you on the frontline of treating COVID patients?
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