Event Medical Cover - Enquiry / Booking Form
Please complete this form as fully as possible for a 'no-obligation' quotation
Organisation / Company Name:
*
Main Contact Name:
*
Address (Of Organisation/Organiser)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Landline/Main Phone Number:
*
-
Area Code
Phone Number
Mobile/Direct Phone Number:
*
-
Area Code
Phone Number
Contact Email
example@example.com
Is your billing address different from the information above?
Yes
No
Billing - Organisation / Company Name:
Billing - Main Contact Name:
Address (For Billing/Invoicing Purposes)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Landline/Main Phone Number:
-
Area Code
Phone Number
Billing Email:
example@example.com
Event Details:
Event Name / Description
*
Event Location
*
Please be as descriptive as possible, especially if this is an outdoor event, over a wider area.
Medical Cover Start Date and Time:
*
/
Day
/
Month
Year
Medical Cover to Start:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
15
30
45
Minutes
Medical Cover End Date and Time:
*
/
Day
/
Month
Year
Medical Cover to Finish:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
15
30
45
Minutes
For Multiple Days, or Multiple Events, please specify required dates and times here:
Specific Activities Taking Place:
*
Tell us a little about your event.
Event Website (Or Online Location for Further Information):
*
Expected Numbers of People Involved:
*
Total Max Overall
Max at any One Time
Participants
Spectators
Staff/Volunteers
How will they be accommodated? (Select all that apply)
*
Standing
Seated
Other
Demographic - Who is the event aimed at? (Please select all that apply)
*
General Public (On the Day)
Pre Booked/Invited (Ticketed) Guests Only
Mainly Children (Under 18's)
Mainly Young Adults
Mainly Middle Aged Persons
Mainly Older Persons
Family Groups
Groups, But not family.
Are any other organisations involved in the provision of Medical Services to this event?
*
If Yes, please describe in detail.
On The Event Day
Who do our team report to on the day?
*
What is their contact number?
*
-
Area Code
Phone Number
Is there a facility available for treating casualties in private?
*
Please provide details, If there is no facility available, we will need to provide this on your behalf
Is Free Parking available to our team?
*
Yes
No
Other
Is Fresh Water available to our team?
*
Yes
No
Other
Please detail the medical resources you feel are required for your event,
*
e.g. Number of Ambulances, First Aid Points, Response Vehicles, Paramedics, Technicians, First Aiders etc.. and estimate how many. (Details of what your last Medical Team supplied would be a good starting point).
Please detail any further supporting information:
*
This might include previous injury/incident data, details of any additional resources that could be made available to our team etc.
Upload any Supporting Documentation:
Browse Files
e.g. Risk Assessments, Maps, Event Specifications etc.
Cancel
of
By submitting this form, i understand that i am requesting a quotation for the services of Centurion Medical Group. I acknowledge that completion of this form does not constitute a firm booking. I have completed this form with the correct information to the best of my knowledge and will undertake to inform Centurion Medical Group of any changes to the information. I have read and will comply with Centurion Medical Group's standard terms and conditions. I will forward all relevant documentation to Centurion Medical Group, including risk assessments, site plans and emergency escalation plans.
*
I Agree
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