Disaster Preparedness Kit Request Form

Disaster Preparedness Kit Request Form

Thank you for your interest in Heart to Heart International's Disaster Preparedness Kits for healthcare workers. Please fill out this form to request the number of kits you would like to receive. As a reminder, these kits should only be given to nurses and/or healthcare workers who do not have the ability to prescribe medication, in accordance with anti-bribery/corruption policies.
Clinic Name
Shipping Contact

First NameLast Name
Shipping Contact Email
example@example.com
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What days of the week can you receive the shipment?

How many of the following staff do you have?

Number of Kits Requested
Do you agree to distribute kits only to nurses and/or healthcare workers who do not have the ability to prescribe medication, in accordance with anti-bribery/corruption policies?
Should be Empty: