Request for Event Medicine

Request Event Coverage: Sports Medicine and Emergency Medical Care

We appreciate your interest in our event coverage services including sports medicine and emergency medical care. To request our services for your event, please fill out the form below. We’ll contact you within 5 business days to let you know if your request has been approved.

Questions? Please call 704-667-2540.

Request form

Before you fill out the form below, please note:
• You must submit your request at least 14 days in advance of the event.
• You must request event coverage for at least 4 hours.

Name of event Date of event (note: if you need event coverage for more than 1 day, please list all dates) Event start time Event end time Event location Street address City State Zip Expected number of attendees Expected number of athlete attendees Age range of athletes Event contact Event contact phone number

Billing Information

Name of company Contact name Street address City State Zip Phone number Email

Medical Coverage information

Type of coverage

Comments or Questions

Enter your comments or questions

I have confirmed that all information above is correct. I acknowledge that I will be charged a Late Fee notice of $100 per event for any request received less than 2 weeks from today’s date. I acknowledge that I will be charged a cancellation fee of $100 if Event Medicine is not notified prior to 24 hours before the event is scheduled.

Request for Event Medicine

Request Event Coverage: Sports Medicine and Emergency Medical Care

Request form

Billing Information

Medical Coverage information

Comments or Questions

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