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UH Screening Event Request

UH Screening Event Request

Fill out the form below to request UH on-site health screenings at your health fair or event.

First Name

Last Name

Organization Name

Telephone

Email Address

Event Name

Event Location Address

Event Location City

Event Location State

Event Location Zip

Event Date

Event Start Time

Event End Time

Event Website

Event Description

Number of attendees expected?

Target Audience

Is this a new event?

No

Yes

Screenings Requested:

Balance

Blood pressure

Body mass index

Bone density

Carotid vascular

Cholesterol Non-fasting

Expert Health Talk

Glucose Non-fasting

Grip strengths

Handouts

Hearing

Hernia

Information Tables

Lower extremity vascular – PAD

Lung Cancer – High Risk

Lung function – Spirometry

Memory Screening

Prostate Screening – PSA

Prostate Screening – PSA & DRE

Skin Screening – Cancer

Stroke risk assessment

Wellness clinic

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