Hurricane Ian - URGENT Need for Hospital Beds

Please complete ASAP no later than 11am, September 29th, 2022.

If you have any questions, please contact:

Mary Mayhew
207-620-0072

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* 1. Please select your hospital name:

Other (please specify)

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* 2. Please select your county:

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* 3. Please complete:

Hospital City:

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* 4. Please complete:

Name for Hospital Contact

Phone Number: *

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* 5. # of currently staffed beds available to accept patient transfers:

Adult

Adult ICU

Pediatric

Pediatric ICU

NICU Level I

NICU Level II

NICU Level III

NICU Level IV

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* 6. Do you have available air or ground transport?

Yes

No

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* 7. If you answered yes to the above, please provide details below:

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* 8. Please insert any additional comments related to this request: