Medical Equipment Order Form

Medical Aid International

Cambridge University Global Health

Medical Equipment Order Form

1.  Application Details

Applicant
Title:
Forename(s):
Surname:
Address:
Telephone (mobile):
Email:
Institution:
Course: / Year of Study:

2.  Elective Details

Details of Institution(s) to be visited:
Estimated duration of visit:
Proposed departure date:
Please provide a brief description of how the equipment you plan to take will be useful for your elective.
On departure from your elective destination,
a)  Do you plan to leave all Med-Aid equipment with the institution(s) you are visiting?
YES NO
b)  Do you plan on bringing any Med-Aid equipment back to the UK?
YES NO
If yes, please state which items you plan on bringing back to the UK:

3.  Equipment

Please check the boxes of items that you would like to include in your packs.

Student Pack
Price per pack:
Sphygmomanometer
Pulse oximeter (£170)
Thermometer
Pen torch
Tendon hammer
Oral Rehydration Salts
Antiseptic powder sachets / Suture pack
Oral Rehydration Salts
Airways (NP/OP)
Nasogastric tubes
IV Cannulas
Bladder syringes
Intraosseous needles
“Giveaway Pack”
Price per pack:
Stethoscopes
Sphygmomanometers
Thermometers
Tendon hammers
Auroscopes
Oral rehydration salts
Ambu bags / Suture packs
Nasogastric tubes
IV Cannulas
Urinary catheters
Kidney bowls
Speculums
Intraosseous needles

I hereby certify that all the information provided above is true to the best of my knowledge.

Signature:
Dated: