Medical Facility Supply Request Form
Please fill this form so that your information and needs can reach suppliers who are able and willing to support you during this high demand period. Please select the closest quantity to your needs. Unite4India is only serving as a point of connection, we do not have the resources to verify supplies. It is the responsibility of the Hospitals and their purchasing managers to verify that the supplies fall under proper standards and approvals including but not limited to FDA 510K. We are not participating in any purchases or exchange of funds. We assume no liability for transactions, supplies or delivery. If you have financial ability to purchase the supplies please disclose on this form. If you do not have the financial ability to purchase the supplies we will look for donor support for you and help purchase the supplies for you.


Thank you for all that you do,

United4India
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Requester First Name, Last Name *
Requester Email *
Requester Phone Number *
Requester Role (MD, RN, Admin, etc) *
Hospital/Institution Name *
Hospital/Institution Address *
Hospital/Institution Purchasing Manager Name
Hospital/Institution Purchasing Manager Contact Info
Supply Drop-off Address and Instructions *
Please describe your most significant shortages: *
Does your Hospital have funds for purchasing all or part of these supplies? *
Are you able and willing to pre-pay or make a deposit before delivery (as some suppliers are requiring)? *
Do you have unit price constraints? *
Materials Needed *
Required
If you selected other, please describe what item(s) you need and in what quantity:
How many oxygen tanks do you need:
Clear selection
How many oxygen meters do you need:
Clear selection
How many oxygen regulators do you need:
Clear selection
How many oxygen concentrators do you need:
Clear selection
How many pulse oximeters do you need:
Clear selection
How many N95 masks with valve do you need:
Clear selection
How many N95 masks without valve do you need:
Clear selection
How many 3 ply masks (ear loop) do you need:
Clear selection
How many surgical masks (tie back) do you need:
Clear selection
How many protective glasses/goggles do you need:
Clear selection
How many isolation gowns do you need:
Clear selection
How many surgical gowns do you need:
Clear selection
How many coveralls/bunny suits do you need:
Clear selection
How many bouffants/head covers do you need:
Clear selection
How many face shields do you need:
Clear selection
How many nitrile gloves do you need:
Clear selection
How many disposable booties do you need:
Clear selection
How many ventilators do you need:
Clear selection
How many thermometers do you need:
Clear selection
How many nasopharyngeal swabs do you need:
Clear selection
How much hand sanitizer do you need (gallons):
How many disinfectant wipes do you need:
Clear selection
How much bleach do you need (gallons):
How much viral media do you need:
Other comments:
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