Public Health Use Chemicals Order Form

Public Health Use Chemicals Order Form
Order chemicals and related supplies for public health use. Please provide your details and select the items you wish to order.
Full Name
First NameLast Name
Organization Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Delivery Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Order Details
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Disinfectant Solution (1L)
Broad-spectrum disinfectant for public health environments.
$24.99Quantity

Protective Gloves (Box of 100)
Disposable nitrile gloves for safe handling.
$17.50Quantity

Chemical Spill Kit
Complete kit for safe containment and cleanup of chemical spills.
$58.00Quantity

Biohazard Waste Bags (Pack of 50)
Heavy-duty bags for safe disposal of hazardous waste.
$22.00Quantity

Eye Wash Solution (500ml)
Sterile solution for emergency eye rinsing.
$13.50Quantity

Total
$0.00
Requested Delivery Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Order Notes or Special Instructions
Should be Empty: