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EMAIL: INFO@HEAVENONEARTHMEDICAL.COM

CALL OR TEXT:

(310)-993-2298 (MAIN LINE)

(323)-513-7689 (SECONDARY LINE)

FULL NAME

First Name

Last Name

COMPANY NAME

(IF APPLICABLE)

EMAIL

PHONE

(###)

###

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REQUESTED BOOKING DATE(S)

MM

DD

YYYY

REQUESTED BOOKING LOCATION

PLEASE INCLUDE THE FULL ADDRESS

WHAT ARE YOU LOOKING TO BOOK?

PLEASE DESCRIBE THE TYPE OF EVENT YOU NEED MEDICAL COVERAGE FOR (E.G., PARTY, CONCERT, RETREAT, SPORTING EVENT, ETC.), INCLUDING DETAILS THAT WILL HELP US UNDERSTAND YOUR SPECIFIC NEEDS.

HOW MANY PEOPLE ARE WE COVERING?

WILL YOUR EVENT INVOLVE ANY INCREASED RISK FACTORS OR POTENTIAL LIABILITIES—SUCH AS ALCOHOL CONSUMPTION, POSSIBLE DRUG USE, PHYSICAL ALTERCATIONS, EXTREME SPORTS (E.G., GYMNASTICS, SURFING, STUNTS), OR OTHER ACTIVITIES THAT MAY ELEVATE THE RISK OF INJURY OR MEDICAL EMERGENCIES?

WHAT IS YOUR BUDGET?

HOW DID YOU HEAR ABOUT US?

NOTES