EVENT MEDICAL SERVICE ENQUIRY
Please allow 1-3 business days from form submission to receive complete Event Medical Service fromal proposal.
Company Name:
*
Contact name:
*
E-mail:
*
Phone Number:
*
Format: (000) 000-0000.
Company Address:
*
Street Address
Street Address Line 2
City
State
Post Code
Name of Event:
*
Eg: Medx Medical Christmas Party
Type of event:
Please Select
Arena - crowd coverage
Cheer competition
Community event
Cycling - BMX
Cycling - Down hill mountain bike
Cycling - road event
Dance competition
Equestrian
Event crowd only - ie: Christmas carols
Festival
Market
Motorcross
Motorsport - offroad
Motorsport - track
Running/ Walking- distances - Marathon to 5km or charity walks
Running - trail running
Sports Medicine - AFL, NRL etc
Water sports
Location of Event:
*
Street Address
Street Address Line 2
City
State
Post Code
Event date - Day 1:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Single day events do not complete the additional days
Event time - Day 1:
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Event date - Day 2:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
If required
Event time - Day 2:
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Event date - Day 3:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
If required
Event time - Day 3:
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Please select who you require medical coverage for:
*
Competitors
Spectators/ Crowd
Other
Do you have specific medical personnel requirements to meet? If yes; please provide level of medical personnel and how many of each level.
If you do not know this information we will recommend qualifications and number of personnel based on similar events
Is there anything additional you think is necessary for Medx Medical Events Coordinator to know for the event that has not been covered?
Example: No access to track via vehicles for DHMTB event
Is there an available site map for the event? Or any additional documentation you would like to provide relevant to the event?
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