Request P&O Goods

  • Final destination of goods: Please provide information about the institution, facility, or location where you will be utilizing the donated supplies.

  • Primary contact: Please provide information about the primary contact for this donation. P.O.C.C. may contact this person to schedule an appointment to pick up the supplies, or to coordinate shipping of the supplies if necessary.

  • Medical professional responsible for supplies received: Please provide the requested information about the medical or allied health professional, either travelling to or at the destination facility, who will take responsibility for the donated supplies. If there is no medical or allied health professional associated with your trip, P.O.C.C. may limit the types of supplies we can provide.

  • Please indicate whether the facility is domestic (within the USA), or international:
  • Are there other prosthetic and/or orthotic facilities in the region you are serving?

  • Ship-to address:
  • Who will pay for shipping expenses, warehouse fees, and import duties (if applicable)?:
  • Will the recipients have to pay for services, and if so, how much?

  • Items requested: Please provide as much detail as possible (quantity, material, size, example manufacturer/part #, etc.).

  • Reference information: Please provide two (2) English-speaking references that we can contact who are familiar with your program and services.


  • Have you or other members of your organization received assistance from P.O.C.C. before?

Release and Indemnity

The medical supplies, prosthetic and orthotic goods, equipment, materials and other items (“Materials”) available from the Prosthetic & Orthotic Componentry Clearinghouse (“P.O.C.C.”) operated by Prosthetic Hope International, Inc. (“PHI” ) are items that would have been discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an “as is” basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes that P.O.C.C and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further recognizes that P.O.C.C, PHI and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials “as is,” with all faults, and acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no circumstances shall P.O.C.C, PHI, the manufacturer or distributor of the Materials or any United States hospital or health care provider that ever owned or used the donated equipment be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees (“Users”) may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property, and death. P.O.C.C, PHI and the recipient organization recognize that this agreement shall release P.O.C.C, PHI and the donor facilities from any and all liability for personal injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials, the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges P.O.C.C, PHI, the donor facilities, and each and every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of P.O.C.C, PHI and the donor facilities (“Released Persons and Entities”) from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save, and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses (including attorneys’ fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities.

By hitting the Submit button below, I hereby agree to the terms above.

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