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Expression of Need
For hospitals and health care facilities
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* Indicates required question
Full name
*
Your answer
Email
*
Your answer
Phone number
Your answer
Name and location of workplace
*
Your answer
Estimated number of staff
Your answer
What demographic do you work with? (i.e. elderly patients, general public, children with low immunity, etc.)
*
Your answer
What are your anticipated needs for equipment and PPE?
*
Your answer
What considerations do we need to be aware of for materials/cleaning/health and safety?
*
Your answer
What quantity do you require?
*
Your answer
When do you need these by?
*
MM
/
DD
/
YYYY
Is there anything else that we should be aware of that we have not asked?
Your answer
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