First Name *

Last Name *

Email *

Phone *

Agency and Location Information

Note: If you are requesting services at multiple locations, please complete a form for each location

Agency Name *

Name of Location *

Street Address *

City *

State *

Zip *

Total Number of Employees at this Location

Cross Streets *

Security Present? * If yes, clearance required? What ID will be required of Affiliated Physicians staff?

Building Access * Please provide entrance location

Parking Instructions Is there a designated visitor entrance?

Main Contact Information

Contact Name *

Contact Office Phone *

Contact Cell Phone

Contact Email *

Back-up Contact Information

Contact Name *

Contact Office Phone *

Contact Cell Phone

Contact Email *

Event Information

Room Selection

Note: This year, to ensure social distancing, each nurse station will require a space that is 10 feet x 10 feet or larger. A designated waiting area that allows employees to wait 6 feet apart from each other is also required. Each nurse requires one table, 2 chairs and a wastebasket (for non-medical wastes). Our nurses will arrive 30 minutes before the event start time to set up.

Event Room Name(s)

Event Room Floor

Other

Are there any other details we need to know?