Common ground donation form

Common Ground Product Donation Form

• Complete this form if you would like to donate items at your booth that match the needs of the Common Ground Health Clinic (see wish list that follows on the next page). • Bring the completed form to HIMSS Central and drop it off at the Common • HIMSS Manager of the Davies Award Program David Collins or HIMSS Manager of Corporate Communications Joyce Lofstrom will contact you to confirm the donation and make arrangements for pick-up. • Contact David Collins at 703-562-8817 and Joyce Lofstrom at 312-804-6439 (cell phones on-site at HIMSS07) with questions. Name__________________________________________________________________ Vendor Company________________________________________________________ Booth Number___________________________________________________________ Cell Phone On-Site_______________________________________________________ Item(s) to donate_________________________________________________________ Common Ground Wish List
indicates high priority
Contact e information.
-Computers & laptops. Must be relatively new. Also: memory, removable storage, blank
media, wireless cards, routers, laser printers, LCD monitors, external cd/dvd burner.
-Uninterruptible power supply & surge protectors
-Copier paper, stationary supplies
-BD, Accencia and OneTouch glucometer test strips
-Pregnancy tests
-Urine Dip Sticks Analysis
-Sterile instruments for suturing and I&D procedures
-Sponsor for clinic faxline (current cost $119/mo for fax, phone, and DSL)
-Pill bottles and lids (new only)
Clinic Diagnostic Materials
-Quick laboratory analyzers for chemistry, hematology, coags, etc.*
-BD, Accensia and OneTouch glucometer strips
-Ear Specula Adult & Child size for Otoscopes
-Ear cleaning equipment and curettes; ear wicks
-Slit lamp*
-Probe covers for thermometers
-Oral/rectal electronic thermometers with probe covers*
-Child, Regular, Large Adult, Ex-Large & Thigh BP cuffs*
-O2 Peak Flow Meters*
-Mouthpieces for O2 Peak Flow Meters*
-O2 Saturation monitors (portable)
-Nebulizers (small, we will give to patients)*
-Non-rebreather Face Masks
-Automatic BP & Vital Sign monitors
-HemeOccult blood testers*
-12 Lead EKG w printer & electrodes*
-23g & 25g 1" needles
-1 cc & 3 cc syringes w 23g or greater needles
-2x2 non-sterile gauze pads
-3x3 non-stick gauze pads
Common Ground Wish List/Clinical Diagnostic Materials continued
-4x4 non-stick gauze pads
-assorted splints: finger, wrist
-CPR masks
-Waterless hand sanitizer
-Iodoform or wound packing
-Sterile dressing kits (sissors & clamps)
-Suture removal kits
-Kidney basins
-Chucks or blue pads
-Quick Strep Tests*
-MonoSpot tests
-Pregnancy tests
-GYN Speculum*
-Slides, slide covers, KOH, normal saline
-Urine Dip Sticks Analysis
-Urine Sample Bottles
Common Ground Wish List/Medications
*Levaquin 500/750
*Amlodipine 5/10
Metformin 500/1000
*Actos 15/30
Triamcinolone Acetonide 0.1% oint 30-120 g *Avandia 4/8
*Lantus Insulin
*Humulin 70/30
*Humulin R
*Advair 100/50, 250/50, 500/50
*Flovent 44, 110, 220
Allergic Rhinitis
*any nasal steroid
*Lipitor 20/40/80
Common Ground Wish List/Medications continued

*Fosamax 70
*Boniva 150
Pain Management
*SoluMedrol 125
*DepoMedrol 40/80
Vitamin C*
Pre-natal vitamins*
*Plavix 75
Antacids Ibuprofen 200/500/800 Tylenol 500 Sudaphed Dextromethorphan Triple ABX Oint Benadryl Hydrocortisone Aspirin 81/325 Thyroid
Levothyroxine 25/50/75/100 mcg
Common Ground Wish List/Clinic Herbal Medicine Needs
Please put packing slip on or mark contents outside box.
*** any lung tonics, immune enhancing, &/or respiratory anti-infective herbs or
00 caps
tincture bottles w/ droppers bottles (1 oz, 2 oz, 4 oz) glass or plastic
(please be sure any bottles or jars are empty and clean)
plastic or glass half ounce or an ounce containers for salves*

Common Ground Wish List/Clinic Herbal Medicine Needs continued
avena (milky oats) tincture & dry herb*
cleavers tincture & dry herb crampbark tincture herb grinder (electric or mortar & pestle) lemon balm tincture & dry herb*
menthol crystals*
st. john's wort oil*
passion flower tincture & dry herb*
california spikenard (aralia californica) tincture grindelia tincture*
wild yam tincture & dry herb*
yarrow tincture & dry herb*
horehound tincture*
chamomile dry herb*
oregon grape tincture*
osha tincture*
thuja tincture & dry herb*
pleurisy root tincture*
marshmallow root dry herb*
nettle leaf dry herb*
vitex tincture*
peppermint dry herb*
Common Ground Wish List/Accupuncture Supplies
-Ear seed called : Vaccaria seed -ear needles (code : DBC Pipe-5 Bulk Pkg - 0.20 x 30 mm)/from OMS 1 - 800-722-8775 -Golden flower ( 1800-729-8509 ) also has good needles (code : VH-3807 )


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