HeartSense Community Screening Request
Thank you for your interest in hosting HeartSense for a free community screening. Please tell us more about your event and we will be in contact with you soon. We provide screenings at community based events, health programs/fairs, employer health events, faith based organizations and more. 
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Event Date *
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Event Name *
Event Location: Address and City *
Event Start Time *
Time
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Event End Time *
Time
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Approximate number of attendees *
Approximate number of attendees age 60 and above *
Contact Person *
Contact Phone Number *
Contact Email *

HeartSense Screening Environment Request:  
For registration - 1 table and 2 chairs and preferably in the area with the most activity of community members

For the Screening Area - 1 table with 4 chairs (2 chairs on each end)

We will need a quieter environment to assess heart sounds properly and greatly appreciate this consideration. 

Will you be able to accommodate these requirements?

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Tell us more about your event! *
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