ALAMEDA COUNTY EMS PPE Request Form
The Alameda County Cal Chiro Association has teamed up with Alameda County Emergency Medical Service to help with the demands of Personal Protective Equipment (PPE). We are specifically serving chiropractors who practice in Alameda County.

The Alameda County EMS has a limited supply of PPE. All providers, including hospitals, who are challenged directly with COVID-19 patients are given priority. The County is allowing only 1 PPE kit per chiropractor for now.

This form should only be used by Alameda County chiropractors that are requesting resources that specifically relate to the COVID-19 incident. This includes medical supplies such as surgical masks, hand sanitizers, gloves, etc. Please continue to check in with your vendors and source new vendors to be able to procure supplies independently. A resource request should only be submitted when your office is unable to procure supplies elsewhere. Please answer the questions as honestly as possible.

If your primary practice is in another county and recently (March 1st, 2020) added a Satellite office in Alameda county in order to get free PPE, then your request is VOID!

Offices located outside of Alameda County should contact their City or County Emergency Operations Center(s) to determine their process. Out of county resource requests will not be filled.

Additionally, we will NOT be filling any requests for household items such as soap, bleach, toilet paper, paper towels, tissues, garbage bags, etc.

We have put together a standard package for you, the doctor. Only 1 package per doctor!

The package includes:
1 Box of 20 masks: Karats Folding Masks GS-PPE250a (N95)
4 Boxes of 50 masks: Standard Ear Loop Masks (Light Blue)
2 Boxes of 100 gloves*: S, M or L
1 Individual Item: JYQ-B001 Digital Thermometer
1 Bottle (gallon): Hand Sanitizer
1 Bottle (gallon): Performex RTU Disinfectant Cleaner.

*Please let us know what size glove you wear.

If you have any questions, please feel free to call me, Dr. Jasmine Danh, DC at 510-509-0170. Thank you.
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Do you practice in Alameda County? *
Required
What is the name of the chiropractor?
What is the address of your office? (include your city) *
What is your chiropractic license #? *
What is your mobile number? *
What is your email? *
How many patients are you seeing per week during this shelter-in-place? *
Do you have an immediate and significant need? *
Have you exhausted your supply, or is exhaustion imminent? *
Have you checked with your internal, corporate supply chain, and/or local jurisdictional partners? *
Have you checked for availability of supplies with your normal external vendors, and "new" vendors to procure material? *
Are you a Cal Chiro Association member? *
How did you find out about this Alameda County EMS PPE service? *
Please check below acknowledging that you understand that the PPE that you are requesting for immediate use in your practice, and that you are not going to sell them or use them for other purposes. *
Required
Due to the volume delivery is not an option. All orders must be picked up. Pick up location will be communicated when order is ready. *
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