Request for COVID-19 Supplies for Your Practice

The AAP-OC Chapter would like to support our chapter members who are in need of supplies for their practice during COVID-19. Please complete the following application. AAP-OC Chapter staff will follow up with you.

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* 1. Please provide a main contact for receipt of supplies.

First Name

Last Name

Title

Email Address

Contact Phone Number

Practice Name

Practice Address

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* 2. List the AAP-OC Chapter member requesting the supplies (Note: at least one provider within the practice must be an AAP-OC Chapter member in good standing)

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* 3. Please select the supplies your practice is requesting

Disinfecting Spray

Disinfecting Wipes

Hand Sanitizer

Gloves

N95 Masks

Surgical Masks

Gowns

Alcohol Wipes

Other (please specify)

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* 4. Justification of Need:
Please include a brief summary of your current need. Include your current patient load, your patient/community demographics, and your estimated quantity of supplies needed.

Please include any additional information to reinforce your need (e.g., underserved patient population, not connected with larger purchasing entity, etc).

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* 5. Does your practice/organization currently offer COVID-19 testing?

Yes

Not yet, but we plan to (provide estimated date below)

Thank you for your application. AAP-OC Chapter staff will be in contact with you soon.

For further information and resources related to COVID-19, please visit our web page:
AAP-OC Chapter COVID-19 Resources

To join the AAP-OC Chapter, please visit:
AAP-OC Chapter Membership