Medical Coverage Request Form

Medical Coverage Request Form

This form is designed to streamline the process of requesting medical coverage for your event. Please provide detailed information about your event, including contact details, event specifics, and medical coverage requirements. The more accurate and complete the information you provide, the more accurate the quote will be. Additionally, this ensures that our medical team is accurately and efficiently staffed and prepared for your event.
Your Name

First NameLast Name
Company Name
Title/Position
Email
example@example.com
Phone Number
Please enter a valid phone number.
How did you hear about us?

ReferralGoogle/Search EngineOnline AdFacebookInstagramOther

Date and Time of Desired Medical Coverage

We recommend scheduling medics at least 30 minutes to 1 hour before and after the event times.
Start Date and Time of Medical Coverage (Pacific Time)

MonthDayYear
Estimates accepted
Hour MinutesAM/PM Option
End Date and Time of Medical Coverage (Pacific Time)

MonthDayYear
Estimates accepted
Hour MinutesAM/PM Option
Multiple Days or Locations?

I need medical coverage for multiple locations and/or multiple days and will list those details in the "Event Details" section or attach a file below.
Level of Service

Number of Medical Staff
Event Medic
An Event Medic is a certified and experienced Emergency Medical Technician (EMT) or Paramedic, who provides professional first aid and Basic Life Support (BLS) for public or private events. This individual possesses the requisite knowledge and skills to manage a wide range of medical emergencies and ensure the well-being of attendees. They are trained to respond quickly and efficiently, with a focus on patient care and safety. Event Medics are adept at working in dynamic event environments and maintain a high level of readiness to address any medical need that may arise.
Number of Event Medics Needed
(EMTs or Higher)
Advanced Event Medic
An Advanced Event Medic is a highly skilled Advanced EMT, Paramedic, or Registered Nurse (RN) with extensive experience and advanced certifications. They are equipped to provide first aid and Basic Life Support (BLS), along with more complex medical interventions, at high-risk or high-profile public and private events. These professionals bring a deeper level of medical expertise to the field, capable of handling severe and life-threatening emergencies. Their advanced training allows them to perform more sophisticated procedures and provide a higher standard of care, ensuring the safety and health of all participants in a demanding event setting.

Perfect for: Large music festivals, Professional sporting events, High-profile award shows, Major TV or film productions, Large-scale corporate events, International business expos, Political rallies or conventions
Number of Advanced Event Medics Needed
(AEMT, Paramedic, or RN)
Medical Staffing Requirements

I have specific staffing requirements above the EMT levelI would like recommendations for medical staffing
Level of Medical Equipment

What level of medical equipment should be furnished?
Medical Kit

Basic First Aid/Trauma KitBasic Life Support Kit - AED + OxygenMedical Station Supplies - Medical Supplies, Signage, Treatment Cot, and BLS Kit (AED, Oxygen, Major Trauma) - (Event will provide Tent(s), Tables, and Chairs)Tent, Tables, and Chairs for Medical Station + Medical SuppliesI would like recommendations for medical kit level
Basic First Aid/Trauma Kit
A basic first aid/trauma kit is designed to handle minor medical incidents and initial trauma care. Typically, this portable kit includes various sizes of adhesive bandages, gauze pads, antiseptic wipes, medical tape, a pair of gloves, scissors, tweezers, a tourniquet, and an emergency blanket. It may also contain splints, a CPR mask, and basic medications like aspirin or ibuprofen. This kit is ideal for treating cuts, scrapes, minor burns, sprains, and other common injuries that don't require advanced medical care.

Basic Life Support Kit with AED and Oxygen
This kit includes all the contents of a basic first aid/trauma kit and adds critical lifesaving equipment. The inclusion of an Automated External Defibrillator (AED) allows responders to address sudden cardiac arrest by providing necessary defibrillation. The kit is also supplied with an oxygen tank and delivery system, including nasal cannulas and non-rebreather masks, to assist patients with respiratory distress. Other additions may include basic airway management tools, a blood pressure cuff, a stethoscope, and various emergency medications. This kit supports basic life support interventions for more serious medical emergencies.

Complete Medical Station
A complete medical station serves as a comprehensive on-site emergency care setup for medical personnel at events or in field situations. This station encompasses all the tools and equipment found in both the basic and BLS kits and integrates additional advanced medical supplies and diagnostic tools. It often includes a portable stretcher or cot, a full range of splinting materials, wound care supplies, and additional first aid/trauma supplies. Monitoring equipment such as a pulse oximeter, glucometer, and portable ECG may be present. It is staffed by professionals who can utilize the array of emergency medications, airway kits, and suction devices. The station is typically housed in a tent or designated area that allows space for patient assessment, treatment, and privacy if needed.
Additional Equipment/Services Requested

BLS (EMT) AmbulanceALS (Paramedic) AmbulanceOn-Site Medical Doctor (MD)Drone Support/FootageEvent Medical Consulting or AdvisementOther
Event Tier Level

Team 1Team 2Team 3
Medic 1 Rate
Medic 2 Rate
Medic 3 Rate
EX: $400 ($350/8 + $50 kit)
Site Contact Name
Site Contact Title
Site Contact Phone Number
Please enter a valid phone number.
Site Contact Email
example@example.com
Event Code
Medic Access Code - Must Save Submission Excel and upload to Patient Care Log/Event Card JotForm
Estimate Link
Admin Emails

Send Client Estimate Prefill email.Send Event Prefill template email.
Expected Weather
Parking Information
CLICK HERE FOR A LIST OF LA COUNTY HOSPITALS AND CAPABILITIES
Hospital: Emergency Department
Name, Address, Capabilities, Distance/Time, Direct ER Phone Number (if possible)
Urgent Care
Name, Address, Capabilities, Distance/Time, Direct to Provider UC Phone Number (if possible)
Police
Fire
Event Start Date
Event Start Time
Event End Date
Event End Time
Event Address
Should be Empty:

Medical Coverage Request Form

Event Information

Event Date and Time

Date and Time of Desired Medical Coverage

Level of Service

Level of Medical Equipment