Hospital Submission Form

All fields are required unless noted otherwise

Name of Hospital

Address (street, city, and region of applicable)

Zip Code (optional)

Country

GPS Address

Why does your hospitals need the supplies? What is the current state of the hospital? What would these supplies mean to your hospital?

Point of Contact

Email (optional)

WhatsApp Phone Number

Type your name as a sworn affidavit that you are the point of contact for this hospital. Typing your name is identified as a signature.