Know Your Medicine: Event Request Form

Please fill out this event request form as best as possible. A representative of our organization will be in touch with you within the next 48 - 72 hours.
Thank you for allowing us the opportunity to serve you!!!

Disclaimer: Please submit event requests at least 6 weeks before the event date if possible. Filling out this form will not guarantee our participation. We will need to review the details of the event to ensure that the event fits our mission.

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    Asthma
    Antibiotic Awareness
    Anticoagulants (blood thinners)
    COPD
    Diabetes
    Heart health (cholesterol, blood pressure)
    Heartburn
    Immunizations
    Nutrition / Weight Management
    Smoking Cessation
    Other (please specify in next question)
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