Establishment Name (via searchable drop down ) Where drop down is a max 5 list of all hospitals queried by search input
Establishment Representative First Name
Establishment Representative Last Name
(Table)
Equipment Type
Equipment Quantity
+ button to add another row
A reCapcha object
A submit button that is activated on reCapcha submission
Message telling the user It is immoral to claim to represent a doctor/nurse/hospital in a manner that would restrict its ability to receive aid. Click to proceed.
Message telling the user their request has been successful (with all the stuff they requested)
Should prompt the user for
+
button to add another row