Please fill out this form to request face shields and straps for your organization.
* = required field
Organization Name*
Qty. of shield kits (frame + shield)* Due to high demand, we are limiting each delivery to 200 face shields. Our face shields are also packed in packs of 10. 01020406080100120140160180200
Does your healthcare organization require a specific material?* Which material should I select? No preferencePLAPETGLaser Cut Budmen (PETG)
Qty. of surgical mask tension release bands* Due to high demand, we are limiting each delivery to 150 mask extenders. Our mask extenders are also packed in packs of 10. 0102030405060708090100110120130140150
Date Desired By* Please give us at least a week to fulfill your order
Message to SoCal Makers Response Team If you need services beyond those offered on this form, please provide details for your request here and we will be in touch if we are able to accommodate it.
Street Address*
Address Line 2
City*
State* ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip Code*
I donated $25.00 or more on the GoFundMe *
This is the person we will contact with any questions, issues, etc.
First Name*
Last Name*
Email*
Phone Number*
Comments, questions, etc.
Products are not FDA cleared or approved, but are authorized by FDA under an EUA for use by healthcare providers as personal protective equipment. Products are only authorized for the duration of the declaration that circumstances justifying the authorization of emergency use under Section 564(b)(1) of the Act, 21 USC 360bbb-3(b)(1) unless the authorization is terminated or revoked sooner.
I have read, understood, and accept this disclaimer.*
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