Request PPE
All responses are required so we can process your request as quickly as possible. Thank you!
What is the name of your hospital or organization? *
Your answer
What type of facility is this?
How did you hear about Make4Covid?
Your answer
Name (First and Last) *
Your answer
Best Contact Number *
Your answer
Email *
Your answer
Preferred Contact Method (select as many as you'd like) *
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Preferred days and times to contact you? *
Your answer
What is the street address for delivery? (no P.O. Boxes) *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Please let us know if you have a specific request for delivery days or times and/or special delivery instructions
Your answer
How many full face shield units do you need? Note that these are reusable. (if none, please enter 0) *
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Your answer
How many visors do you need (they attach to the headband)? (if none, please enter 0) *
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Your answer
How many additional clear shield units do you need? Note that these are reusable. (if none, please enter 0) *
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Your answer
How many face mask ear savers would you like? (if none, please enter 0) *
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Your answer
How urgently do you need this equipment? *
We have plenty of PPE in stock
We have no PPE in stock
Please let us know if you have any of the following additional PPE needs. We’re continually working on getting other equipment designs approved and we will notify you if they become available. (Select all that apply)
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