We are so thankful to be able to provide for medical needs free of charge. Please submit this form if you have a medical supply or equipment need. Once your form is received, you will be contacted via email to confirm that we have what you are requesting and to set up an appointment time to pick up at the warehouse. If you have questions about what types of supplies and medications we might have available, please refer to the information sheet at the top of this page.
PLEASE NOTE: Submitting this form does NOT automatically schedule your appointment to pick up your requested supplies. You will be contacted once we receive your form to CONFIRM we have what you need and to CONFIRM an appointment time for your pick up. Please allow AT LEAST 3 business days for us to receive and process your request. If your request is being made when our warehouse is closed, please allow additional time for a response.
Submitting this form indicates that you are intending to pick up these supplies as soon as possible. If you are not intending to pick these supplies up right away, please indicate the date you would like to schedule in the "Additional Notes" section below. We will wait until that time to pull your requested supplies and send your appointment confirmation.
SUBMITTING THIS FORM DOES NOT AUTOMATICALLY SCHEDULE YOUR APPOINTMENT. YOU WILL BE CONTACTED TO CONFIRM AN APPOINTMENT TIME. All drop offs and pick ups at the warehouse are BY APPOINTMENT ONLY.
What medical supplies do you need? (this list needs to be as detailed as possible - also please give height/weight of person using equipment so we can ensure the proper size for the requested equipment)
SPECIAL NOTE: if your list is longer than 10 items AND/OR you are requesting supplies for an organization or international location, please use the Organization/International Request Form on the previous page.