On Line Event Form

Your Name:         

Company You Represent: (1)

Your Email Address:

Business Phone:   Business Fax: Cell Phone:

I am contracting Heart Screen for the following event(s):

Cholesterol    
Blood Pressure #of Stations   Flexibility
Body Fat  #of Stations   Aerobic Conditioning
Grip Strength   #of Stations   Body Fat  #of Stations

BMI 

Do you want us to monitor this YES

   Grip Strength #of Stations
Thyroid (TSH)    
PSA  

Health Risk Assessment

 
Metabolic Testing #of Machines    
Lung Function   ASI-Stroke Prevention
Bone Density   Adjunct Services
UV Photo    
DUEyes    
Visual Acuity    
Glaucoma Screening    
Hearing Screening    
     
Wellness Wagon    
Massage # of Therapists    
Nutrition Workshop  Topic  

Yoga  or Tai Chi

    
Stress Management Seminar    
     
Other
     

Event is to be held on: Day of Week:      Date:    2010

_____________________________________________________________________________

EVENT LOCATION INFORMATION (2)

COMPANY NAME:

LOCATION CONTACT:

CONTACT PHONE:

CONTACT EMAIL:

LOCATION ADDRESS:

CITY ST: ZIP:

FLOOR/ROOM:

TOTAL NUMBER OF PEOPLE IN COMPANY:

NUMBER EXPECTED TO ATTEND:

BILINGUAL NEEDS: Yes No

_____________________________________________________________________________

BILLING INFORMATION

Bill company listed in # (1)

Bill Company listed in # (2)

Your request, when received by Heart Screen, will be acknowledged within 24 hours. An emailed confirmation of this event will follow within 24 hours and your event will be reserved on Heart Screen’s calendar. Please call if it is not received. 631.842.1122

  
 

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