Event Medical Cover - Enquiry Form - Centurion Medical Group

Event Medical Cover - Enquiry / Booking Form

Please complete this form as fully as possible for a 'no-obligation' quotation or to provide event information to our team. If you need assistance with completing this form, please contact us on 0300 302 0575.
Organisation / Company Name:*
Main Contact Name:*
Address (Of Organisation/Organiser)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landline/Main Phone Number:*

Area CodePhone Number
Mobile/Direct Phone Number:*

Area CodePhone Number
Contact Email
example@example.com
Is your billing address different from the information above?

YesNo
Billing - Organisation / Company Name:
Billing - Main Contact Name:
Address (For Billing/Invoicing Purposes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landline/Main Phone Number:

Area CodePhone 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:*

DayMonthYear
Medical Cover to Start:HourMinutes
Medical Cover End Date and Time:*

DayMonthYear
Medical Cover to Finish:HourMinutes
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:*

Rows	Total Max Overall	Max at any One Time
Participants
Spectators
Staff/Volunteers

How will they be accommodated? (Select all that apply)*

StandingSeatedOther
Demographic - Who is the event aimed at? (Please select all that apply)*

General Public (On the Day)Pre Booked/Invited (Ticketed) Guests OnlyMainly Children (Under 18's)Mainly Young AdultsMainly Middle Aged PersonsMainly Older PersonsFamily GroupsGroups, 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 CodePhone 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?*

YesNoOther
Is Fresh Water available to our team?*

YesNoOther
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. Cancelof
By submitting this form, i understand that i am requesting a quotation for the services of Centurion Medical Services. 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 Services of any changes to the information. I have read and will comply with Centurion Medical Services standard terms and conditions. I will forward all relevant documentation to Centurion Medical Services, including risk assessments, site plans and emergency escalation plans.*

I Agree
Should be Empty:

Event Medical Cover - Enquiry / Booking Form

Event Details:

On The Event Day