Request Form Full Name Verification Please provide verification that you are a family caregiver or a caregiver in an assisted living facility or group home. Address Please provide your address to which we should ship the masks and your contact information. City State Zip Code Email Phone DISCLAIMER: Please note that Eunity Solutions has purchase these masks from a third party manufacturer. You agree that you will not under any circumstances sell any of the masks given to you by Eunity Solutions. By submitting this form, you are taking full responsibility for the quality, safety of these masks and their use. SUBMIT We will contact you to coordinate delivery as soon as your request is approved. Based on availability, we will reach out on a first come basis.