Request Supplies

Complete this form, along with your requested list of supplies and a $100 donation plus shipping, to help cover the cost of procuring and storing supplies. 


RECIPIENT ORGANIZATION/HOSPITAL/INSTITUTION/HEALTHCARE FACILITY

Select Date

Top 5 Treatments or Services (E.g.: HIV Testing, Family Health, Dental, Etc.)

Total Staff at Facility:

What Kind and Number

Do you have a Biomedical Engineer or Clinical Engineer on Staff? If YES, please provide contact information. If NO, how is biomedical equipment and instrumentation evaluated and fixed?

What Kind and Number
What Kind and Number

Transportation

If you require AFYA to deliver supplies directly to the recipient country, please complete the following:

Consignee/Recipient Information:

This is the entity that is the official recipient of the donated medical supplies. The consignee may be the institution utilizing the materials OR may be a charitable organization receiving the donation for onward delivery to the entity who will use and/or distribute the donated materials.

You must provide a physical address. We cannot deliver medical supplies to a P.O. Box.

Notify Party/Clearing Agent Information

We will send all official shipping documents by courier to this individual at the address provided. The individual will utilize the documents to clear customs and remove the container from port.

Upon completion of this document, please be sure you attach a list of requested materials including consumable/disposable supplies, single use items, durable medical goods, electrical biomedical equipment, and surgical tools.

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