Medical Requestion Form

Request Medical Equipment

If you or someone you know works for a healthcare institution and is in need, complete this form to submit a request.

By filling out this form, you agree to allow Hire Ground to disclose the information you provide to Hire Ground, consistent with COVID-19 Suppliers’ mission to connect personal protective equipment (PPE) suppliers to those who need it most–the healthcare providers at the frontline.

Purchasing Contact Name*
We need the name and contact information of an individual who is authorized to make purchases for your organization.
Purchasing Contact Email*
Purchasing Contact Phone*
Type of Organization
N95 masks (next 30 days)*
Are you willing to pre-pay or make a deposit before delivery?
Most suppliers are requiring deposits and or prepayment terms and conditions before delivery.
Do you have any unit price constraints?
What is the maximum price you are willing to pay for NIOSH-compliant N95 masks? If none, please say None.
Additional mask requirements
Would you consider purchasing FDA-approved KN95 masks if N95 masks are not available?
Isolation gowns (next 30 days)
Number of ventilators (invasive) needed
Number of ventilators (non-invasive) needed
Are there any other medical equipment or supplies required? What quantities?
Name of institution(s)*
Your profession/role (Doctor, Researcher, Department Chair, etc)*
Requester Name*
Requester Phone Number*
Number of beds at your institution(s)
Institution Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hospital
Nursing Facility
Dental Office
Clinic
City, County, or State Office
Transit
Grocery or Convenience Store
Restaurant, Retail Food, and Food Delivery
Other Retailers
Pharmacy or Medical Supplies Provider
Home Healthcare Services
Construction
Media Services
Gas Station, Auto Supply, and Auto Repair Shop
Bank, Credit Union, and Insurance
Property Maintenance
Laundromat and Dry Cleaner
Hotel and Motel
Veterinary Clinic
Other