PPE Request Your name* Your email* Your telephone Ext: What Department do you work in?* Home HealthHospiceRehab CenterStaying WellCommunity HealthOffice Staff Pick up date* Pick up location* RidgefieldNew Milford What do you need? Gloves Small (2 boxes at a time) Medium(2 boxes at a time) Large (2 boxes at a time) X-Large(2 boxes at a time) Gowns Small Gowns(10 at a time)Medium Gowns(10 at a time)Large Gowns(10 at a time)X-Large Gowns(10 at a time)XXL Gowns(10 at a time) Hair and Shoe Covers Shoe Covers (10 pairs at a time) Hair Covers (10 at a time) Masks Surgical Masks (1 box at a time) KN95(10 at a time) Fit Tested N95 (FOR COVID-19 POSITIVE PATIENTS OR ANY OTHER PATIENT REQUIRING AIRBORNE PRECAUTIONS) BYD N95 (10 at a time) 3M 1860S N95(10 at a time) 3M 8110S N95 (10 at a time) Makrite 9500 N95(10 at a time) DOBU 2D Model 201B N95(10 at a time) 3M VFlex 1804 N95(10 at a time) 3M Aura 9205+ N95(10 at a time) Eye protection Face Shields (5 at a time) Goggles (1 per person–to be reused!) Sanitizing Hand Sanitizer Big (1 big pump bottle – 8oz) Hand Sanitizer Small (2 small bottles) Hand Soap (1 bottle at a time) Paper Towels (1 roll at a time) Sanitizing Wipes (2 packages at a time) Alcohol Prep Pads (50 individual pads at a time) Barriers (60 at a time) MRSA Kit MRSA Kit (1 Kit at a time) Name of Patient with Contact Precautions Flu vaccine request for administration in home (nurses only) – Please note that our inventory is low and requested doses may not be available, we will reach out to you if we are unable to fulfill this request. Fluad High Dose (age 65 and up) – Number of doses needed —Please choose an option—123 Flucelvax Quadrivalent (age 19 and up) – Number of doses needed —Please choose an option—123 VFC Quadrivalent (age 6 months – 18 years)- Number of doses needed—Please choose an option—123 If you feel these quantities do not correlate with the number of patients you see please let us know. Comments: