Request for Mobile Care Unit service
Name
*
First Name
Last Name
Organization
*
Contact email
*
example@example.com
Contact phone number
*
-
Area Code
Phone Number
Date of event
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start time
*
End time
*
Description of event
*
Estimated attendance
*
Age range of attendees
*
example: 18 and older
Location of event
*
I am requesting the mobile clinic for the following services:
Point of Care Services
A1C
Hemoglobin
Glucose
Urinalysis
Pregnancy test
Weight / Height
Blood pressure / Pulse
Vaccinations
COVID-19 Vaccines
Pfizer adult (1st, 2nd + booster)
Pfizer kids (1st + 2nd)
Moderna (1st, 2nd + booster)
Health Education
Diabetes
Hypertension
Nutrition
Medication
COVID
Pre-natal
Other
Please verify that you are human
*
Submit
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