EMG Health Fairs -Exhibitors & health Professionals Registration Form
Please fill out this form fully so that we can have a more streamlined process of getting you proposals to participate in our health & wellness events.
Email address *
What is the name of your practice or business
Your answer
Please put your address (If you have multiple offices just put the address of the main office you should be contacted at)
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
First Name (this should be the first name of names of the person we should contact)
Your answer
Last name (this should be the last name of names of the person we should contact)
Your answer
Phone number (Please put phone number & cell phone number & what number is best to contact you on)
Your answer
What is the Dr's or health professional's full name
Your answer
List all specialties or health topics etc... (For example Dentist, Chiropractic Care, Acupuncture, Nutrition Massage etc... )
Your answer
Insurance Specifications. what plans do you accept in the network and what plans do you accept out of the network ? (Please give as much info as possible)
Your answer
What interactive service or mini screenings survays etc... can you provide at a health fair ? (if you don't have one we will help work with you to find one to help get the employees & tenants more involved)
Your answer
How far would you go to do a health & wellness event (Please specify the distance or areas such as all of Manhattan or specify streets and avenues etc... keep in mind the further you willing to reach the more events you are likely to receave)
Your answer
Please list full addresses for any other office locations
Your answer
Please list your practice or business website
Your answer
If you have more information about what is needed & wanted please let us know
Your answer
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