Request for Medical / Dental Supplies and Equipment

Hospitals of Hope collects and distributes medical supplies and equipment for use at clinics and hospitals serving the poor both in the United States and around the world. To request supplies and equipment for your mission team, hospital, or clinic, please complete and submit this form.

Contact Name:

First: Last:

Contact Mailing Address:

Street: City: State:

Zip Code: Country:

Contact Phone: Alternate Phone :

Contact Email:

Organization Name:

Type of organization:

Would you like to be included on our mailing list?
no

 

Who will be the ultimate recipient of these donated items?

What are the dates of your trip?

By what date do you need these supplies?

Will a physician go along on this trip? If so, what is his/her name?

Please list needed supplies and equipment. If more space is necessary, please email your complete list to info@hospitalsofhope.org.