Donation medical equipment and goods

Fields marked with a * are mandatory. Please complete the form. If you cannot send the goods yourself, we will contact you to arrange for transportation. We appreciate it if you would care about sending the equipment as complete as possible including tubes, cords, manuals etc. By reasons of regulations we cannot accept drugs.

Name of donor (hospital, manufacturer, etc.)*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact person*
First Last
Phone*
Mobile phone
E-mail*
Donation of equipment and goods 1
Please mention kind of equipment or goods, type and age. Is the equipment still working and complete. If not, what is missing or how damaged is it. If applicable, please mention expiry dates.
Donation of equipment and goods 2
Please mention kind of equipment or goods, type and age. Is the equipment still working and complete. If not, what is missing or how damaged is it. If applicable, please mention expiry dates.
Donation of equipment and goods 3
Please mention kind of equipment or goods, type and age. Is the equipment still working and complete. If not, what is missing or how damaged is it. If applicable, please mention expiry dates.
Donation of equipment and goods 4
Please mention kind of equipment or goods, type and age. Is the equipment still working and complete. If not, what is missing or how damaged is it. If applicable, please mention expiry dates.
You may upload files like photos of equipment and goods (max 1.4MB)
Accepted file types: jpg, pdf, gif.
If you need more memory for your pictures, please send them via email to info@medic.nl