PPE Order Form

If you have any questions or issues completing the form, please email HMMSCOVID19@hmms.on.ca.

Terms of Agreement
By submitting this form and by receiving Personal Protective Equipment (PPE) from the Ontario Health West Supply Chain process, you agree that:
•Your organization is in compliance with Ontario Health’s recommendations for PPE use during COVID-19 pandemic;
•Your organization will indemnify, defend and hold harmless Ontario Health, and any organization’s operating our distribution/logistics locations including their directors, officers, employees, agents and contractors from any and all claims from your organization or any third party for any losses, expenses, costs, injuries, harm, damages or liabilities, or any causes of action, actions, claims, demands, lawsuits or other proceedings in any way based upon, occasioned by, attributable to, arising out of or by reason of the distribution or use of the PPE.
•Your organization shall notify Ontario Health immediately upon commencement of or threat of any claim, suit or action brought or may be brought against any parties in relation to the distribution or use of the PPE.
•Your organization shall use all PPE in accordance with the manufacturer’s instructions, and in accordance with all applicable federal and provincial laws.
Additionally, I have verified or will verify and confirm that any Personal Protective Equipment (PPE) I receive from Ontario Health will remain in Ontario, and will be used for direct patient care. Further, the PPE received will not be resold or redistributed without the express written consent of Ontario Health.

Please note, these supplies should not be used to create a stockpile.

By clicking this box, you have read and accepted the Terms of Agreement*

Date*

Organization Name*

Sector of Care*

LHIN*
Please select your LHIN. Follow the link http://www.lhins.on.ca to identify the Ontario Health Region / LHIN

Street Address*

City*

Postal Code*

Contact Name*

Contact Phone Number*

Contact Email Address*

Please click if your organization is Indigenous led/governed

Is your organization currently in COVID outbreak?*

Yes No

Inputs Required to Process your Order

# of Patient-Facing Clinical Staff and/or Learners or Pharmacists in your practice or organization?*

# of Non Clinical Staff in your practice or organization?*

# of Clients/Patients your practice/organization services?*

On average, how many clients/patients do you see daily?*

Provincial Products Available
Please select the items that you require

Gowns

Gloves

Masks

Face Shield

Hand Sanitizer

Disinfectant Wipes

Send me a copy of my responses

Email address