American Medical Resources Foundation, Inc..

Online application and request for medical and hospital equipment and supplies.

I Answer all the questions completely. Do not leave any questions blank. If the question does not apply, please write N/A.
II A separate request must be submitted for each hospital involved.
III After answering all of the questions, follow the directions to print out two forms which must be signed and mailed back to us.
IV Please also mail us a statement from the government of the recipient hospital's country that the hospital is exempt from that governments taxes and import duties.
   
Thank you for using our online form.

 

1.  Name of requesting institution (ministry, foundation, etc.):
Name of requesting institution:  

Contact Person and Title:

2.  Address of requesting institution:
Please state physical address as well as mailing P.O. Box Address
Number and Street
City, State:
P.O. Box, Mailing Address
Telephone/Fax:
E-Mail:
Physical Delivery Address
Physical Delivery Address if different from the above: This is required for Customs purposes and shipments can not occur without this information.
Institutional name:
Number and Street
City, State:
P.O. Box, Country
Telephone/Fax:
E-Mail:
 
3.  Representative or Contact Person in USA or Canada, if any:
Name and Title  
Street and Number:  
City, State:  
P.O. Box, ZIP:  
Phone/Fax:  
E-Mail:  
     
4.  Desired port of entry:  
5. Customs Broker name:
Name of Customs broker:
Address:  
Phone/Fax:  
E-Mail:  
 
 6. General Community Description   
Description
Total community population served:  
Population under 15 years
Population over 60 years
Women of child bearing age
Average annual income (USD)
7. The equipment will be used to:
 
8. Describe the legal status of the institution.  
9.  Current Institutional Characteristics:
General Medical Care: InpatientOutpatient  
Surgical Care: InpatientOutpatient
Specialized Care:
 
 
 
Please list the primary diseases or conditions that you address:
 
 
 
10. Is your organization connected with the Ministry of Health in relation to its programs?  
11.  The institution (or sponsor) is able to provide the following:
  A donation to cover costs of inland transportation, inspection, testing, repair, storage, export packing, ocean freight shipping.
  On-site equipment installation and personnel training.
  Maintenance of equipment.
12. How will AMRF donated medical equipment help your facility and the people that you server?  Please describe what problem will be addressed by the AMRF donated equipment and the reasons for your request.  Please state how wit will be used, who will use it, and who will benefit from it.

13. Technical Specifications and Restrictions
Limits on size of equipment, if any  
Limits on weight of equipment, if any:
Electricity:Volts  
Electricity:Cycles  
Availability of electricity:
Electricity reliability:
14. Physical and Personnel Characteristics of the institution:
Building: Size in square meters:
Building material:
Total number of beds:
Number of emergency beds:
Number of bassinets and cribs:
Number of incubators:
Total number of employees:
Number of Engineers, Equipment Technicians
Number of Doctors
Number of Dentists
Number of Nurses
Number of Dieticians
Number of Pharmacists
15.  Please tell us whether the institution needs technical assistance and/or training of personnel in the following fields:
Equipment Installation Technical Assistance   Training
Use of equipment Technical Assistance   Training
Equipment Maintenance Technical Assistance   Training
Other specify
YOUR NEEDS AND DONATED EQUIPMENT
The equipment supplied is used but has been tested and is functional.  It has not been repainted, refurbished or re-manufactured.  There may be dents, scratches and normal wear visible on the equipment.  Please not that such items as x-ray, beds, and OR tables are often more than 10 years old but in good working condition.  For reasons of infection control AMRF cannot ship used mattresses with any beds.  Mattresses generally are provided with gurneys and stretchers.  Goods are strictly forbidden for resale.
16 Are there any age restrictions as to how old a device can be? 
17.Are there any items that cannot be shipped, such as clothing, furniture, or similar items?
   

The following list is organized by medical practice area and lists those items generally donated and available; AMRF cannot guarantee that they will be available when your request is being filled.  If certain items that you require are not on this list, please add them under the "Other" within a category and we will do our best in providing them to you.  Please list how many you request in the Quantity Needed column.
Please enter how many of each item you need in the text field.
DESCRIPTION  ID# AREA

Quantity Needed

CHAIR, DENTAL 1

DENTAL

DENTAL TOWER  2 DENTAL

INSTRUMENTS/DENTAL  3 DENTAL

X-RAY/DENTAL  4 DENTAL

5 DENTAL
6 DENTAL
7 DENTAL
ANALYZER/BLOOD CHEMISTRY 8 DIAGNOSTIC

ANALYZER/BLOOD GAS 9 DIAGNOSTIC

AUDIOMETER 10 DIAGNOSTIC

CAMERA/GAMMA 11 DIAGNOSTIC

CENTRIFUGE/FLOOR  12 DIAGNOSTIC

CENTRIFUGE/HEMOCRIT  13 DIAGNOSTIC

CENTRIFUGE/REFRIGERATED  14 DIAGNOSTIC

CENTRIFUGE/TABLE TOP/1 SPD  15 DIAGNOSTIC

CENTRIFUGE/TABLE TOP/VAR.  16 DIAGNOSTIC

CHLORIDE METER/OSMOMETER  17 DIAGNOSTIC

COMPUTER/CARDIAC OUTPUT  18 DIAGNOSTIC

COUNTER/BLOOD CELL  19 DIAGNOSTIC

CYSTOSCOPE  20 DIAGNOSTIC

DOPPLER/VASCULAR  21 DIAGNOSTIC

EEG  22 DIAGNOSTIC

ELECTROMYOGRAPH (EMG)  23 DIAGNOSTIC

GLUCOMETER  24 DIAGNOSTIC

HEART RATE DET./FETAL  25 DIAGNOSTIC

LAMP/SLIT  26 DIAGNOSTIC

LARYNGOSCOPE  27 DIAGNOSTIC

MAMMOGRAPHY UNIT  28 DIAGNOSTIC

MANOMETER/ANEROID  29 DIAGNOSTIC

MANOMETER/MERCURY  30 DIAGNOSTIC

METER/pH  31 DIAGNOSTIC

MONITOR/C02/CAPNOMETER  32 DIAGNOSTIC

MONITOR/ECG/HEART RATE  33 DIAGNOSTIC

MONITOR/ECG/HR/BP  34 DIAGNOSTIC

MONITOR/ECG/HR/RESPIRATION  35 DIAGNOSTIC

MONITOR/FETAL  36 DIAGNOSTIC

MONITOR/HOLTER  37 DIAGNOSTIC

MONITOR/NEONATAL  38 DIAGNOSTIC

MONITOR/OXYGEN  39 DIAGNOSTIC

PULSE OXYMETER  40 DIAGNOSTIC

RECORDER/EKG  41 DIAGNOSTIC

SPIROMETER  42 DIAGNOSTIC

SPIROMETER/RECORDING  43 DIAGNOSTIC

THERMOMETER  44 DIAGNOSTIC

ULTRASOUND/ABDOMINAL*  45 DIAGNOSTIC

ULTRASOUND/CARDIAC*  46 DIAGNOSTIC

ULTRASOUND/VASCULAR*  47 DIAGNOSTIC

X-RAY LAMP  48 DIAGNOSTIC

X-RAY VIEW BOX  49 DIAGNOSTIC

X-RAY/C-ARM  50 DIAGNOSTIC

X-RAY/FILM PROCESSOR  51 DIAGNOSTIC

 52 DIAGNOSTIC

X-RAY/PORTABLE  53 DIAGNOSTIC

54 DIAGNOSTIC
55 DIAGNOSTIC
56 DIAGNOSTIC
BASSINET 57 INPATIENT

BED/ELECTRIC 58 INPATIENT

BED/MECHANICAL 59 INPATIENT

BED/PEDIATRIC 60 INPATIENT

CABINET/BEDSIDE 61 INPATIENT

CABINET/MEDICINE 62 INPATIENT

CABINET/PATIENT BELONGINGS 63 INPATIENT

CART/UTILITY 64 INPATIENT

CHAIR/GERIATRIC 65 INPATIENT

CHAIR/VISITOR 66 INPATIENT

CHAIR/WHEEL 67 INPATIENT

COMMODE 68 INPATIENT

CRIB 69 INPATIENT

CRUTCHES (PAIRS) 70 INPATIENT

DEFIBRILLATOR 71 INPATIENT

INCUBATOR/NEONAT TRANSP 72 INPATIENT

LIFTER/PATIENT 73 INPATIENT
POLE/IV 74 INPATIENT
SCALE/IN-BED 75 INPATIENT
STRETCHER/WHEELED 76 INPATIENT
TABLE/BEDSIDE 77 INPATIENT
TABLE/OVERBED 78 INPATIENT
WALKER 79 INPATIENT
80 INPATIENT
81 INPATIENT
82 INPATIENT
BATH/PARAFFIN 83 LABORATORY
CULTURE MEDIA 84 LABORATORY
DILUTER 85 LABORATORY
INCUBATOR (LAB) 86 LABORATORY
INCUBATOR/LABORATORY 87 LABORATORY
MICROSCOPE 88 LABORATORY
PHOTOMETER/FLAME 89 LABORATORY
PIPETER 90 LABORATORY
PIPETTES 91 LABORATORY
SCALE/BALANCE 92 LABORATORY
SHAKER 93 LABORATORY
SPECTROPHOTOMETER 94 LABORATORY
WATER BATH 95 LABORATORY
96 LABORATORY
97 LABORATORY
98 LABORATORY
ANESTHESIA MACHINE* 99 OR
ANESTHESIA ACCESSORIES 100 OR
BLOOD WARMER 101 OR
ELECTROSURGICAL, UNIT 102 OR
HYFRICATOR 103 OR
INSTRUMENTS/SURGICAL 104 OR
INSUFFLATOR 105 OR

LIGHT/OR/CEILING 106 OR

LIGHT/OR/MOBILE 107 OR

MONITOR/EXPIRED GAS 108 OR

PUMP/POST-OP 109 OR

STERILIZER/ETO 110 OR

STERILIZER/REQUIRES STEAM 111 OR

STERILIZER/STEAM/SELF-CONT 112 OR

STERILIZER/TABLE-TOP 113 OR

SURGICAL SUPPLIES 114 OR

SUTURES 115 OR

TABLE/DELIVERY 116 OR

TABLE/FRACTURE 117 OR

TABLE/OPERATING* 118 OR
119 OR
120 OR
121 OR
CUTTER/CAST 122 OUTPATIENT

EXAM TABLE 123 OUTPATIENT

LAMP/EXAMINlNG 124 OUTPATIENT

OPTHAL/OTO SCOPE 125 OUTPATIENT

SCALE/INFANT 126 OUTPATIENT

SCALE/STANDUP 127 OUTPATIENT

128 OUTPATIENT
129 OUTPATIENT
130 OUTPATIENT
BRONCHOSCOPE* 131 SPECIAL

COLONOSCOPE* 132 SPECIAL

ENDOSCOPE* 133 SPECIAL

GASTROSCOPE/ESOPHAGOSCOPE* 134 SPECIAL

LARYNGOSCOPE 135 SPECIAL

LIGHT SOURCE 136 SPECIAL

PROCTOSCOPE* 137 SPECIAL

138 SPECIAL
139 SPECIAL
140 SPECIAL
ANESTHESIOLOGY 141 SUPPLIES

BANDAGES & DRESSINGS 142 SUPPLIES

CARDIOVASCULAR 143 SUPPLIES

CLINICAL 144 SUPPLIES

DENTAL 145 SUPPLIES

DERMATOLOGY 146 SUPPLIES

EAR/NOSE/THROAT 147 SUPPLIES

EMERGENCY ROOM 148 SUPPLIES

ENDOCRINOLOGY/METABOLISM 149 SUPPLIES

LABRATORY 150 SUPPLIES

LAPAROSCOPIC 151 SUPPLIES

NEPHROLOGY 152 SUPPLIES

NEUROLOGY 153 SUPPLIES

NUTRITIONAL 154 SUPPLIES

OBSTETRICS/GYNECOLOGY 155 SUPPLIES

ONCOLOGY/HEMATOLOGY 156 SUPPLIES

OPERATING ROOM 157 SUPPLIES

OPHTHALMOLOGY 158 SUPPLIES

ORTHOPEDIC 159 SUPPLIES

PATHOLOGY 160 SUPPLIES

PEDIATRIC 161 SUPPLIES

PULMONARY 162 SUPPLIES

RADIOLOGY 163 SUPPLIES

RHEUMATOLOGY 164 SUPPLIES

THORACIC 165 SUPPLIES

UROSTOMY/OSTOMY/COLOSTOMY 166 SUPPLIES

167 SUPPLIES
168 SUPPLIES
169 SUPPLIES
BOOKS/MEDICAL 170 SUPPORT

CART/FOOD 171 SUPPORT

COMPUTER 172 SUPPORT

FREEZER 173 SUPPORT

PRlNTER/COMPUTER 174 SUPPORT

REFRIGERATOR/FOOD 175 SUPPORT

REFRIGERATOR/BLOOD 176 SUPPORT

TYPEWRITER 177 SUPPORT

178 SUPPORT
179 SUPPORT
180 SUPPORT
AMBU BAG 181 THERAPY

CONCENTRATOR/OXYGEN 182 THERAPY

DIALYSIS/HEMO 183 THERAPY

DIATHERMY/RF 184 THERAPY

DIATHERMY/ULTRASOUND 185 THERAPY

HYDROCULATOR 186 THERAPY

HYDROTHERAPY TUB 187 THERAPY

HYPO/HYPER THERMIA 188 THERAPY
HYPOTHERMIA/PAD 189 THERAPY

IPPB THERAPY (RESPIRATOR) 190 THERAPY
IV PUMP 191 THERAPY

IV CONTROLLER 192 THERAPY

IV/SYRINGE PUMP 193 THERAPY

LAMP/WARMING 194 THERAPY

LIGHT/BILLI 195 THERAPY

MATTRESS/AIR 196 THERAPY

NEBULIZER/SPRAYER 197 THERAPY

NEBULIZER/ULTRASONIC 198 THERAPY

PHYSICAL THERAPY 199 THERAPY.

PUMP/FEEDING 200 THERAPY

SUCTION/TRACHEAL/GOMCO 201 THERAPY

SUCTION/WALL REGULATOR 202 THERAPY

SUCTION/WOUND 203 THERAPY

TOURNIQUET/AUTOMATIC 204 THERAPY

TRACTION FRAME 205 THERAPY

VENTILATOR/ADULT 206 THERAPY

VENTILATOR/NEONATE 207 THERAPY

WARMER/INFANT 208 THERAPY

209 THERAPY

210 THERAPY

211 THERAPY

 * - These items are no longer available on a donation basis.
but we can assist on the purchase of them in the used
equipment market and add the cost to the program.

     

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