Product Donation Request Form

If your organization is seeking donations of medical products, please complete the form for consideration. All donations are subject to internal review and product dissemination is at the sole discretion of Welch Allyn's partner organizations.

Please provide Welch Allyn with your contact information.

* indicates required field.

First Name:*

Last Name:*

Check here if you are affiliated with a 501c3 non-Profit organization.

Tax-Exempt or Non-Profit ID #:

Affiliated Organization:

Email Address:*

Address 1:

Address 2:

Country:*

City:*

Zip/Postal Code:*

Phone:

Fax:

Products Requested:

Product Number:*

Please describe the project as well as the intended usage of the product requested.

Product Description:*

If different from above:

Please indicate where the requested product will be used.

Healthcare Facility Name:

Contact Person - First Name:

Contact Person - Last Name:

Company Web Address:

Email Address:

Address 1:

Address 2:

Country:

City:

Zip/Postal Code:

Phone:

Fax:

Sponsoring Organization or Foundation Information:

Organization Name:

Contact Person - First Name:

Contact Person - Last Name:

Organization Web Address:

Email Address:

Address 1:

Address 2:

Country:

City:

Zip/Postal Code:

Phone:

Fax:

PanOptic Ophthalmoscope

MacroView Otoscope

MicroTymp 4 Portable Tympanometer

KleenSpec Single Use LED Vaginal Specula

Connex Spot Monitor

FlexiPort Disposable Blood Pressure Cuffs

ProBP 2000 Digital Blood Pressure Device

Braun ThermoScan PRO 6000

Diagnostic Cardiology Suite

ABPM 7100 Ambulatory Blood Pressure Monitor

Green Series 300 General Exam Light

Home Blood Pressure Monitors

Hypertension Program

Home Blood Pressure Monitors

Welch Allyn Home Scale

Request a Product

Product Donation Request Form

Product Donation Request Confirmation

Please provide Welch Allyn with your contact information.

Products Requested:

If different from above:

Please indicate where the requested product will be used.

Sponsoring Organization or Foundation Information:

North America

Asia & Pacific Rim

Europe, Middle East, Africa & India

Latin America

PanOptic Ophthalmoscope

MacroView Otoscope

MicroTymp 4 Portable Tympanometer

KleenSpec Single Use LED Vaginal Specula

Connex Spot Monitor

FlexiPort Disposable Blood Pressure Cuffs

ProBP 2000 Digital Blood Pressure Device

Braun ThermoScan PRO 6000

Diagnostic Cardiology Suite

ABPM 7100 Ambulatory Blood Pressure Monitor

Green Series 300 General Exam Light

Home Blood Pressure Monitors

Hypertension Program

Home Blood Pressure Monitors

Welch Allyn Home Scale

Request a Product

Product Donation Request Form

Product Donation Request Confirmation

Please provide Welch Allyn with your contact information.

Products Requested:

If different from above:

Please indicate where the requested product will be used.

Sponsoring Organization or Foundation Information: