N-95 Eligibility Form
Payment will be taken after approval and upon follow up contact from Ladd Safety. If an order goes unfulfilled, all funds will be refunded. Please review all questions and note those that are required. Our goal is to source small, private practices with 3M N-95 masks at a pre-pandemic market rate. Filling out this form is not a guarantee of order delivery, as 3M ultimately decides necessity. You will be contacted by a representative from Memphis Medical Foundation or Ladd Safety regarding the status of your order and to process a purchase order. NO FOLLOW UP CALLS PLEASE. 3M is only providing status updates in the event of an approval.
Contact Number for Order Follow Up
*
-
Area Code
Phone Number
Contact Name for Order Follow Up
*
First Name
Last Name
Practice Name
*
Specialty
*
What type of practice are you? (Choose One)
*
Hospital-based
Surgery Center
Outpatient
Dental
Briefly Describe your N-95 use (where, type of procedure, etc.). If you are seeing COVID-19 patients, please note that in the box as well.
*
What hazards will you be protecting yourself from (gas in dentistry, generally close proximity to patients, head and neck procedures, etc.)?
*
Shipping Address (Enter one address you would like masks shipped to)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you interested in ordering the 3M 8210 Non-Valved Mask? PLEASE NOTE: the minimum order for this mask is 160 masks @ $154 total plus, tax, shipping and any applicable credit card charges paid by the purchaser.
*
Yes - if you click yes, please fill out the next three questions
No
How many employees will be using 3M 8210 Non-Valved Masks daily?
Type number of employees here
How many 3M 8210 Non-Valved Masks per employee per day?
Type number of employees here
Is this mask required for employees, or is it provided on a volunteer basis?
Required
Voluntary
Are you interested in ordering the 3M 8511 Valved Mask? PLEASE NOTE: the minimum order for this mask is 80 masks @ $197.20 total plus, tax, shipping and any applicable credit card charges paid by the purchaser.
*
Yes - if you click yes, please fill out the next three questions
No
How many employees will be using 3M 8511 Valved Masks daily?
Type number of employees here
How many 3M 8511 Valved Masks per employee per day?
Type number of employees here
Is this mask required for employees, or is it provided on a volunteer basis?
Required
Voluntary
Submit
Should be Empty: