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Pulse Oximeter Request Form

1. Requestor’s Information
(This person that will be responsible for managing all requests and will be contacted directly) *This question is required.
2. What is the delivery address? Please note: the delivery must occur in New York City.  *This question is required.
3. Hours for deliveryPlease select days and times you are able to accept a delivery. 
Space Cell Start timeEnd time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
4. Is your organization non-profit?
 
5. What percentage of the practice’s patient panel is uninsured or publicly insured?
 
0 out of 100% Total
By submitting this form, you are notifying the New York City Department of Health and Mental Hygiene (the Department) that you are authorized to speak for the organization named above, and that the organization is in need of the supplies you have described as part of its response to the COVID-19 pandemic. The Department will consider these needs in planning the distribution of supplies as part of its ongoing response to the COVID-19 emergency. The Department may share your information with partner organizations that can help procure and/or deliver supplies to your organization.
 
The Department does not guarantee that all needs submitted through this form will be met.

PLEASE NOTE: The requested items are currently being provided by the City and the requestor will NOT incur any potential costs.


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