| Requestor:
|
* Indicates a required field. |
| *Name of person requesting the program |
A value is required. |
|
*Date of Request |
A value is required. |
|
*Phone Number |
A value is required. |
|
*E-Mail Address |
A value is required.Invalid format. |
*Representing (Company, HMO, Hospital, Broker, Other)
|
A value is required. |
| |
|
| Billing Information: |
|
| *Name |
A value is required. |
| *Phone Number |
A value is required. |
| *Email Address |
A value is required.Invalid format. |
| |
|
| Event: |
|
|
*Representing (Company, HMO, Hospital, Broker, Other) |
A value is required. |
|
*Name of Event Location: |
A value is required. |
|
*Date of Program |
A value is required. |
|
*Day of Program |
A value is required. |
|
*Event Address |
A value is required. |
|
*Event Phone # |
A value is required. |
|
*Contact Name |
A value is required. |
*Time of Event
(set up or tear down not included) |
From:
To:
A value is required. |
|
Expected number of attendees |
|
| Bilingual (Spanish) |
Yes
No |
|
Inside
Outside
TBD
|
|
Hold Date:
Yes
No Confirm Program/ Send Confirmation:
Yes
No |
|
Single Site Event:
Yes
No |
Multiple Site Program:
Yes
No |
|
|
Services to be offered: |
|
| By the person: |
|
Total Cholesterol
Test Minimum
Max
TBD
(no fasting necessary) |
Glucose
Test Minimum
Max
TBD
(no fasting necessary) |
TC/HDL
Test Minimum
Max
TBD
(no fasting necessary) |
Lipid Profile
Test Minimum
Max
TBD
(Total Cholesterol, HDL, Triglycerides & Glucose – 12 hours fast required) |
Flu Immunization
Shot Minimum
Max
TBD
|
| |
| By the Hour: |
| Blood Pressure
|
Number of Staff
|
| Grip Strength
|
Number of Staff
|
| Body Composition
|
Number of Staff
|
| DermaScan
|
Number of Staff
|
| Lung Function
|
Number of Staff
|
| Osteoporosis
# of Machines
# staff per Machine: 1
2
3
|
| Seated Chair Massage
|
# of Therapists |
| Presentation
Topic
TBD
|
| |
To calculate the cost of your program, just refer to the Service and Fee Schedule on our web site.
Thank you for submitting this information. HealthFax will respond back to you via e-mail and or by phone to confirm your event. |
| |
HOME 
HealthFax Service and Fee Schedule