Humanitarian Product Donation Request Form

Thank you for contacting us. Please provide all of the requested information below. This information will be considered in our careful review and evaluation of your request. Include any additional material you feel will support this request, such as your organization’s mission statement on letterhead.

Donation requests should be submitted at least 12 weeks prior to the event start date. Urgent requests will be considered on a case-by-case basis, with no guarantee of a decision made in time to accommodate the delivery of the product by the requested date.

Individual Information
Organization Information
Humanitarian Mission Details
Experience and Education with the Requested Product/Equipment

If possible, we are happy to set up an education session with a local representative for your area to ensure everyone is properly educated, as this is imperative to successful treatment. If you would like our assistance with product/equipment education, please provide the following information.

Once we have received all of the necessary information and it has been reviewed, we will notify you if Teleflex will support your request or not. All approved requests will be processed as soon as possible.

If you do not receive a confirmation email upon submitting your request, please reach out to

If you are unable to submit your request through our web site you may submit the following information via one of the following methods:

Mail to:
Teleflex Medical
Humanitarian Program Coordinator
118 Broadway Street, Suite 227
San Antonio, TX 78205

Fax: +1-919-328-1396

Please include a signed Letter of Request on the requesting organization’s letterhead that includes the following detail:

  • The Organization’s legal name, address, and phone number
  • Contact information for authorized representative of the organization
  • Type of medical outreach
  • Overview of the sponsoring agency
  • Dates and location of medical mission
  • Date product is needed to meet organization’s shipping schedule
  • A specific list of products/item number(s), quantities required
  • Number of patients expected to be treated
  • Procedure(s) expected to be performed
  • Number of Health Care Providers participating
  • Experience and education of participating operators/providers with the requested product/equipment:
    • Have all anticipated operators/providers received product/equipment education?
    • Who will educate inexperienced users?
    • Would you like to request an education session with a local representative to ensure operators/providers are properly educated?

Please include:

  • a copy of organization's W-9 form (US) or comparable non-US tax information document
  • confirmation of tax-exempt/non-profit status from IRS, if applicable