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LeConte Medical Center - request for health fair

When requesting a Health Fair or on-site screenings for your group or organization, we ask that you please give us at least 45 days notice to evaluate your request. We apologize that we cannot accommodate all requests, but look forward to discussing your request with you.

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Name
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Email
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Telephone
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Address1
Address2
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City
State
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Zip
  
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Type of Event:
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Name of Event:
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Date of event (Please note, a 45 day notice is required.):
Time of event:
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Organization name:
Address:
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Person Making Request:
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Phone #:
Email:
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Event Contact Person:
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Phone #:
Email:
Is this a new event?
If not, what was last year's participation?
If corporate event, please list your company's insurance provider:
Are any other health care providers involved?
Will there be any advertising or media coverage?
If yes, then please provide details:
Will you have volunteer support?

 Request for (check the best category):



 

Target Audience (check all that apply):
Estimated attendance:
Additional information:
Security Code
Type Security Code

SUBMIT