Offsite Services Request
This form is for the scheduling of screening and service events. Please carefully read the following prompts and respond accordingly. You will receive an update on your request within 48 hours.
Name
*
First Name
Last Name
Company Name
Job Title
Phone Number
*
Please enter a valid phone number.
Work Email
*
example@example.com
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of Service Site (if different from Company Address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date & Start/End Times of Service
*
I would like to schedule for the following screenings:
*
All services on this list
COVID-19
HIV
Diabetes
Blood Pressure
Depression
None
Other
I would like to schedule for the following services:
*
All services on this list
COVID-19 Vaccine
COVID-19 Booster
COVID-19 for (child/ren)
Flu-Shot
Dental Clinic
Home Visits (elder care)
School Health Education/Service
None
Other
Event Description (include if event will be inside or outside, number of tables and chairs required, how many people expected to attend)
*
Other (Event Comments or Questions)
Please verify that you are human
*
Submit
Should be Empty: