Request Supplies

Organization Information

Organization Name

Contact*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title

Email*

Phone (Include Country Code)*

Fax

Type of Organization

Support Group
Clinic
Hospital
Other

Ship To

Organization Name

Attention

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you use an agent or different contact, please provide Company Name, Contact, Address, Phone & Email information below:

Information about Ostomates Receiving Supplies

Is membership required to receive products?

Yes
No

If membership is required, what is the charge for membership (in US Dollars)?

Do you provide ostomy supplies to ostomates at no charge?

Yes
No

If no, explain.

Is there a health care professional able to select the right size and type, and teach how to use these ostomy products?

Yes
No

Other comments regarding how you provide help to ostomates:

How many patients with either a colostomy or ileostomy need supplies per month?

How many patients with a urostomy need supplies per month?

Product Selection Information

How many drainable pouches do you need per month? (normal usage is 8 drainable pouches per person per month)

Enter monthly quantity under each size.

Colostomy & Ileostomy

Size range & type of product

One Piece Products

Two Piece 1-1/2 inch (38mm)

Two Piece 1-3/4 inch (45mm)

Two Piece 2 1/4 inch (57mm)

Two Piece 2 3/4 inch (70mm)

Two Piece 4 inch (100mm)

Total Colostomy & Ileostomy Products

Urostomy

Size range & type of product

One Piece Products

Two Piece 1-1/2 inch (38mm)

Two Piece 1-3/4 inch (45mm)

Two Piece 2 1/4 inch (57mm)

Two Piece 2 3/4 inch (70mm)

Two Piece 4 inch (100mm)

Total Urostomy Products

Can you use additional two piece CLOSED pouches?

Yes
No

If yes, enter quantity needed per month:

45mm

57mm

70mm

Can you use one-piece pouches with Karaya seals?

Yes
No

Can you use colostomy irrigation equipment?

Yes
No

If yes, how many people use the irrigation?

Can you use ostomy supplies for babies or children?

Yes
No

Please provide an age range of your pediatric population:

Under 1
1 - 3
4 - 6
7 - 9
10 & Over

Are there any other ostomy supplies not listed on this sheet that your patient population can use?

Shipment Information

The closest airport is:

Kilometers from you:

The closest seaport is:

Kilometers from you:

FOW-USA sends an invoice, packing slip, and letter stating this is a charitable donation. What other documents do you need to import these supplies? For example, a Certificate of Donation or a Memorandum of Understanding. Please email a copy of any additional documents needed to: supplyrequest@fowusa.org

Are USA embassy stamps needed?

Yes
No

Do you have/need an import license to receive our supplies?

Yes
No

If yes, please scan and email your current license to: supplyrequest@fowusa.org

What agency grants the license in your country?

Is there a limit on the value of a charity donation per shipment?

Yes
No

If yes to the above, how much? (in US Dollars)

Other Information

Do you consent to the use of stories and pictures you provide FOW-USA in our newsletter, Facebook page, and website?

Yes
No

Please provide any other information that will help us choose the correct products for your mission and the people you serve:

Ostomates and health-care providers donate supplies to us. Then, volunteers sort and pack the supplies for shipment to you. While we try to choose types and sizes of products that you request, we may not be able to meet all your needs. We can only pack supplies that are available from the donations to us.

One Piece & Two Piece Colostomy & Ileostomy products in each carton there may be a mix of several brands and will include drainable and closed, cut-to-fit, pre-sized stoma openings, flat flanges and convex flanges.

Urostomy products are packed by brand and flange size. Flat and convex flanges are packed in each carton. Night drainage and leg bags are packed when available.

Ostomy Accessories: Skin prep wipes, adhesive remover wipes, paste, powder, seals, skin barriers, & belts are packed in each carton when available.

A detailed packing slip is attached to each carton.

FOW-USA provides supplies free of charge to you and pays the shipping charges to your port of entry. FOW-USA does not pay duties, customs charges, or storage charges. It is your responsibility to secure all documents necessary to import the shipment as a duty-free charity donation and pick up the shipment at port of entry before storage charges begin.

Products are for humanitarian purposes – not for resale.

I have read the above and agree to these terms for requesting a donation from FOW-USA.

Organization

Name