#COVID19 CARES Pack Request Form

Please fill out this form to request a CARES pack, which will include some face masks. As we ourselves are facing a shortage of Personal Protective Equipment, these are meant for our patients that are high-risk and/or cannot leave to get such supplies. We will contact you for a pickup time and/or delivery time if you cannot leave your house. Filling this form out does NOT guarantee you will receive one; however, we will do our best to meet the needs of our dear patients who need it the most on a first-come first-served basis.

Please DO NOT call our office with this request.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Checkbox

Check the boxes that apply to you:

I'm requesting the CARES pack for myself

I'm requesting the CARES pack for someone else

I am a high-risk individual (asthma, bronchitis, emphysema, immnocompromised, older than 65)

I live with high-risk individuals

Number of CARES pack requested:

At this time, we are limiting a max of 2 packs per family. Leave us a comment if your circumstances are different.

One Pack

Two Packs

Delivery/Pickup Options

Please select one

Message/Comments

Our Office

1560 E Debbie Ln, Ste 108
Mansfield, TX, 76063
United States