PPE Order Form - General Practice Living with COVID Program

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

PPE Order Form - General Practice Living with COVID Program

I acknowledge that Country SA PHN can only provide limited quantities*
- Yes
I/We are caring for COVID patients and those with respiratory symptoms using telehealth only as a part of the Commonwealth Living with COVID program and only wish to access the use of pulse oximeters*
- Yes
I/We are caring for COVID patients and those with respiratory symptoms face to face as a part of the Commonwealth Living with COVID program
PPE Bundles (1 per provider) - click on the + button to add a new row, 1 row per GP
GP Name GP Provider Number Quantity of Full PPE Bundles P2/N95 Respirator Size S/M Glove Size S/M/L
PPE Top Up Order - I understand that the table below can be used to order individual items in the rare circumstances that stock is damaged in transit
P2/N95 Respirators S/R (90 units) Goggles Face Shields (40 units) Gowns (40 units) Gloves S/M/L (100 units) Surgical Masks (80 units) Hand Sanitiser (1 bottle)
Please identify who and where the PPE should be sent to:
First Name*
Last Name*
Job Title
Organisation Name*
Number of Providers at Your Site*
Address*
Suburb*
State*
Postcode*
Please enter your contact details below should we need to get in touch:
Email Address*
Mobile Number*
Order delivery instructions (eg deliver to back of practice)
Consent
By submitting this form to Country SA PHN
- 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 practitioner 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.

GP Name	GP Provider Number	Quantity of Full PPE Bundles	P2/N95 Respirator Size S/M	Glove Size S/M/L

PPE Order Form - General Practice Living with COVID Program

PPE Order Form - General Practice Living with COVID Program

I/We are caring for COVID patients and those with respiratory symptoms face to face as a part of the Commonwealth Living with COVID program

Please identify who and where the PPE should be sent to:

Please enter your contact details below should we need to get in touch:

Consent