Recipients RecipientsContact InformationThank you for tapping into The ReCARES Network!Any information we collect is for demographic purposes and will support our efforts to secure funds that are needed to continue and improve our services in the community. No individual data will be shared with any funders, partners, stakeholders or volunteers; only aggregate (summary) data may be shared.Your personal data will remain anonymous. Your name and signature will be required initially to set up a patron account, with a number, for you. The account will incorporate our liability waiver and allow us to serve you more efficiently on return visits without the need to complete a paper form on each visit—saving you time and sparing our environment!Who are you picking up for? Myself Friend/Family Healthcare Client My Organization (Bulk)First NameLast NameMy Organization(Bulk)Some description about this sectionFirst NameLast NameName of OrganizationHealthcare WorkerAre you here on behalf of a healthcare agency or another patient?First NameLast NameFriend/FamilyWhat is your name?First NameLast NameAgencyPhone NumberEmailOrganization Website URLClient InformationPlease provide responses about the end user of the equipment or supplies being recieved.First NameLast NameAge– Select –Under 5 years5-17 years18-24 years25-34 years35-44 years45-64 years65-84 years85-99 years100 years and overEmailDescriptionQuantityMailing AddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweRace/EthnicityBlack or African AmericanAmerican Indian and Alaska NativeAsianNative Hawaiian and other Pacific IslanderHispanic or LatinoWhite or CaucasianIncome Level– Select –$0 – $15k$16k-$30k$ 31k-$75k$76k-$150k$150k+Preferred Language– Select –EnglishSpanishMandarinCantoneseFilipino/TagalogVietnameseKoreanPersianHindiPersian/Iranian/FarsiArabicOtherWhat gender do you identify as Female Male Non-Binary Would Rather Not SayWhat gender does your friend/family member identify as? Female Male Non-Binary Would Rather Not SayWhat gender does your patron identify as? Female Male Non-Binary Would Rather Not SayWhat most closely describes your current living situation? Stable Transitional UnhousedWhat Insurance do you currently have? Medicare Medi-Cal/Medicaid Employer Sponsored/private Not insuredWhich Medicare Plan do you have? CMS Kaiser Permanente Blue Shield Anthem Blue Cross Health Net Cigna AetnaWhich Medi-Cal/Medicaid plan do you have? San Francisco Health Plan Alameda Alliance for Health Marin Kaiser Permanente Blue Shield Anthem Blue Cross Health Net CCHP AetnaWhat is your reason for coming to ReCARES? Prefer not to buy new equipment to protect the environment Items are too expensive and/or not covered by insurance Takes too long for insurance to cover itemsItem Picking UpWhat item(s) will be picked up today? Item Description Quantity Wheelchair/Transport chairWalkerRollatorCaneCrutchesCommodeToilet Seat Riser/HandlesShower Chair/Seat/StoolTub/Shower Transfer BenchIncontinence Supplies (packages)Knee ScooterIce MachineBlood Pressure Monitor KitLiquid Nutrition (cases)Other Medical Supplies (sm)Other Medical Supplies (md)Other Medical Supplies (lg) $100+Other DME SMOther DME MDOther DME LG $100+ I have read and agree to the Terms and Conditions and Privacy PolicySubmit Form
