COVID Response Supplies
We've created this form to efficiently collect vital information about your need. Your department information will not be disclosed to third parties. Your information will not be added to marketing or mailing lists.

All supplies will be made available either at or below wholesale cost. Qualified purchasers and organizations must be actively engaged in front-line, professional response to Coronavirus.
Contact Full Name *
Your answer
Contact Email *
Your answer
Contact Phone *
Your answer
Can we contact you via text message? *
Affiliated Organization *
Organization Zip Code *
Your answer
Organization State *
Two letter code (e.g. MN)
Your answer
How urgent is your overall situation? *
Well supported and equiped
Critically under supported and equiped
What is the infection risk to your personnel? *
Low
High
Do you expect resupply of critical supplies from State/Federal authorities? *
How many COVID patients is your organization currently responsible for? *
Rough or ballpark numbers are OK
Your answer
How many COVID patients does your organization anticipate being responsible for?
Rough or ballpark numbers are OK
Your answer
We Need These Items
Check all that apply - include any other needs in the "other" column and we will try to help
How many people need these supplies? *
Your answer
Organization Full Shipping Address (Include Receiving Contact Name & Phone) *
Your answer
Comments and Notes
Your answer
Submit
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