UAC PPE Request Form
WARNING: Please do not use an embedded browser like Webchat to submit this form. Copy the link to a mainstream browser to start your application.
We are United Against Covid-19 (UAC), an alliance of healthcare professionals, psychotherapists, social workers, donors, and volunteers.

Many healthcare and research experts believe this pandemic is a lasting battle. At UAC, our mission is to unite everyone’s individual power and, together, win this fight against COVID-19.

The purpose of this form is to help those who are in urgent need of PPEs and to save lives. Please fill out as much of this form as possible so that we can properly handle your request. The submission of this form goes to a password-protected Google spreadsheet.

If you are willing to donate money for our purchase of PPEs, please visit our fund raising campaign at uac-heroes.org/gofundme. Your contribution will be greatly appreciated.

Please note that UAC is a small-scale operation, which is run by unpaid volunteers who are dedicated to donate PPEs that are qualified and legitimate. UAC has no affiliation to any PPE suppliers or their products.

We will reach out to you once we find a match to your request(s).
Your Name *
Your email address *
Your phone number *
US phone number in one of the following formats with or without extension: (123) 456-7890x12345, 123-456-7890x12345
Name of the hospital/organization you belong to *
City/State of the entity in previous question *
Select Healthcare or Public setting this donation goes to *
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