Deterra Product Request

***If this is an emergency or you are experiencing chest pain, shortness of breath, or an allergic reaction, please call 911 or report to your closest Emergency Room immediately. Do not use this form for urgent medical needs.

Inspira Health provides the Deterra product to community agencies in Gloucester, Cumberland and Salem counties free of charge. In an effort to measure the impact, we request that you promote the survey to those who receive the product.

To submit a request for a supply of Deterra, please complete the form below. Once request is confirmed, product will be available for pickup by appointment only. We offer two locations in Woodbury and Bridgeton.

Agency Name

Spell out agency name, no abbreviations please.

First

Last

Street Address

Street Address 2

City

Zip Code

County

Date of Birth

Email Address

Phone Number

Number of units requested

Individual Requests limited to 3 pouches per request. Agency Request limited to 300 pouches.

Inspira is proud to offer this product to communities throughout our service area.

Distribution method including target audience

How did you hear about Deterra?

May we send you health information by email?

Yes

If you have questions about the Deterra product and community outreach, please contact us at CommunityBenefits@ihn.org or (856) 575-4130.

CAPTCHA

Math question 9 + 11 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.