Copy of Organization Supply Request Form

International Supply Requests

Thanks for reaching out to Mission Regan! We are so thankful to be able to provide for medical needs free of charge. Please submit this form if you requesting for an international destination.

Once your form is received, we will contact you to confirm that we have received your request. If you have questions about what types of supplies and medications we might have available, please refer to this information sheet.

Please note our supplies are a mix of unexpired and gently expired, and it is not always possible to seperate them.

Include EVERYTHING you may be needing. Prioritize if some things are more important than others.

Let us know the volume of boxes you are able to pick up. Are you expecting a few boxes of supplies (10?) or do you want as many boxes as possible (1000+?).

Please note that we do not make any shipping arrangements in our office. If applicable, shipping and transport arrangements will be made by you.

Indicate whether expired items are ok. (Expired supplies? Expired meds? Expired IV fluids?)

For extensive international lists, we prefer two months notice to allow for list processing, packing, and pick up scheduling.

Give a date range for when supplies are needed. It may take up to two weeks for staff to process your list and determine if we have what you are looking for.

PLEASE NOTE: Submitting this form does NOT automatically schedule your appointment to pick up your requested supplies. You will be contacted within 3 days of receiving your form to confirm we have received and are processing your request. Please allow AT LEAST 1 month for us to receive and process your request.

Primary Contact First Name

Primary Contact Last Name

Phone

Organization Name

Organization Website

Final Destination of Supplies

Please upload a typed spreadsheet of supplies and details of needs here.

(this list needs to be as detailed as possible - sizes, strengths, quantities, priorities, expired status, etc) For more information, please refer to the information at the top of this page.

Upload Supply List

What is your status on taking expired supplies

All expired supplies are okay, including medications and/or fluids.

Expired supplies are okay, but NOT expired medications and/or fluids.

We cannot take ANY expired supplies, medications, and/or fluids.

How many boxes are you prepared to accept -- A few boxes (10?) or as many as possible (1000+)?

What is your timeline for picking up supplies? (Keep in mind we may need up to TWO MONTHS to prepare a larger supply list for pick up.)

International Supply Requests

Subscribe to our newsletter