request-for-medical-coverage

Visitor Restrictions Update: Due to COVID-19, visitor restrictions are in place. Learn more.

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.

Event Information

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

Medical Coverage Information

Type of coverage

Comments or questions

Enter your comments or questions

I have confirmed that all information above is correct.

Once you submit this form, it will serve as a contract for services with your organization.

If an event is cancelled without notice, a non-cancellation fee will be charged.

Request Event Coverage: Sports Medicine and Emergency Medical Care

Request form

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