PPE Order Form Allied Health Emergency Response

Please complete the form here and we will be in touch regarding your request.

PPE Order Form - Allied Health Emergency Response

I acknowledge that Country SA PHN can only provide limited quantities*
- Yes
Certification that I:
- Am not receiving free PPE from other sources
- Agree to order only the required quantities per eligible allied health provider
- Will not sell any products provided by the Commonwealth under this arrangement
Please identify who and where the surgical masks should be sent to:
Organisation Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of contact
Phone
Mobile
Email
Emergency Provision PPE - can only be accessed where there is no local supply available commercially, or from another State or Territory government scheme.
I have attempted to obtain through a commercial supplier*
- Yes
Surgical Masks (1 Box) Please enter quantity below
Consent
Untitled
- I agree that the details provided in this form are true and accurate and all eligibility requirements have been met.
- I agree I have not previously ordered PPE for the same allied health provider in the last 4 weeks.
- I consent to the collection, use and disclosure of my personal information to the Australian Government Department of Health, Primary Health Networks, Logistics and Distribution Partners, who will deliver the vaccines and related products to the Pharmacy site. This information may also be used for auditing purposes.
- If the details above contain personal information, other than my own, I have obtained consent from the person to whom the personal information relates to for the collection, use and disclosure of this personal information to the Primary Health Networks, Logistics and Distribution Partners, and to Australian Government Department of Health for ordering, auditing, and delivery purposes.

PPE Order Form Allied Health Emergency Response

PPE Order Form - Allied Health Emergency Response

Please identify who and where the surgical masks should be sent to:

Emergency Provision PPE - can only be accessed where there is no local supply available commercially, or from another State or Territory government scheme.

Consent