Changing Hands Request

Changing Hands Request

Use this form to contact the Changing Hands staff to request or donate equipment.

Request Type*

Select

First Name*

Last Name*

Email Address*

Preferred Phone*

Street Address

City*

State

PA

Zip Code

Briefly describe your request*

Services are being considered are for:

Select or enter value

Urgency of equipment requested:

Select

How did you hear about us?

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If other, please describe

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