Individual Patient Delivery Requests for SF Patient Pantry

Patient Pantry

The SF Patient Pantry serves low-resourced pregnant and parenting families during the COVID-19 pandemic. We provide basic necessities such as diapers, formula, food/produce, hand soap and toothbrushes etc. Our next deliveries will be next Tuesday and Wednesday. Thank you!
Due to a decrease in volunteer drivers we are limiting our home deliveries for patients under special circumstances such as: Quarantine, New Born Delivery, Recent Surgery and Mobility Impairment. If other please describe.
Instructions

1. Fill out the following form to request a delivery to your patient. 2. Make a note in the patient chart that they consent to their information being shared with the Patient Pantry. 3. Let the patients know that some requested items may not be available on their day of delivery.
When will delivery occur?

We deliver on Tuesday and Wednesday afternoons (usually 12-3 pm). We aim to complete deliveries within 1-7 days of the request. If your patient has an urgent need please email lindahuerta@homelessprenatal.org to coordinate a pick up.
Please fill out the following information about the patient so that we can successfully deliver the item(s).

This form is HIPAA Compliant
Does your patient consent to sharing their personal information with the Patient Pantry and its partners in order to keep track and receive funding? *

Yes (please document in the patient's chart) No

Collapse Stopper
What kind of delivery method does your patient need? *

Pick Up at 2500 18th St. San Francisco Home Delivery
If your patient needs a home delivery, please select the reason *

Quarantine New Born Delivery Surgery Mobility Impairment
Is the patient's household currently under quarantine? *

Yes No
What neighborhood best describes the patient's address? (this helps us group deliveries efficiently) *

Bayview-Hunters Point Bernal Heights Excelsior Ingleside Mission Mission Bay Oceanview Portola Sunnydale Tenderloin
Patient's preferred language(s)? *

English Spanish
Patient/Contact Name *

First Name Last Name
Patient Age
Patient/Contact Phone Number (please confirm with patient, do not assume number in chart is the best contact number): *

Area Code Phone Number
Patient delivery location (please confirm with patient, do not assume address in chart is the delivery address): *

Street Address

Street Address Line 2

Postal / Zip Code
What food items does the patient need? *

Groceries (for families who can cook) No cook food bag (for families that do Not have access to a kitchen) No food items
Any FOOD preparation considerations? (e.g. No access to kitchen or refrigeration)
What baby item[s] does the patient need?

Baby wipes Baby cereal Baby/kid girl clothes Baby/kid boy clothes Newborn formula (Enfamil) Newborn formula (Similac)
If you are requesting clothes, what size?
0-6m, 6-12m, 12-18m 2T, 3T, etc
What personal care item[s] does the patient need? (Hygiene Products)

Hand soap Toothpaste/Toothbrushes Pads
What medical care item[s] does the patient need? (COVID positive patients only)

Hand sanitizer Masks
How many ADULTS live in the household? (this will help us pack appropriate amount of items)
How many CHILDREN live in the household? (this will help us pack appropriate amount of items)
Please list the age(s) and gender of the children in the household
What size diaper[s] does the patient need?

Newborn Size 1 Size 2 Size 3 Size 4 Size 5 Size 6 Pull-Ups 2T Pull-ups 3T
What type of sleep surface does your patient need for their infant? Or any other special item[s].

Breastfeeding Pillow,
Anything else you would like us to know about this patient?
Name of person filling out this form: *

First Name Last Name
What clinic/organization are you affiliated with? *
Email address of person filling out this form: *
example@example.com
Is this patient already a client of one of the following community-based organization that provides services? *

Black Infant Health CalFresh Family Resource Centers (SF Human Services Agency) Homeless Prenatal Program SF Marin Food Bank Pantry None
Would the patient be available to pick up these items in person? (For faster service) *

Yes No
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Patient Pantry

Due to a decrease in volunteer drivers we are limiting our home deliveries for patients under special circumstances such as: Quarantine, New Born Delivery, Recent Surgery and Mobility Impairment. If other please describe.

Instructions

When will delivery occur?