Baptist Health Mobile Health Unit (MHU)Request Form

Thank you for your interest in scheduling the Baptist Health’s Mobile Health Unit. To request the MHU, please return the following information to us at least 2 months prior toyour event. Upon receipt of your request, someone will contact you within 5 business days to discuss your event and let you know if the MHU is available. We cannot guarantee availability for all requests. If questions arise, please give us a call at 501.202.1540

Host Organization Name: *

First Name: *

Last Name: *

Phone Number: *

Email Address *

What is the Name of Your Event?

What is the date of Your event?

What is the address of the event?

Number of Attendees Expected *

Start Time: *

End Time: *

Event Details:: *

Please answer the following questions:

1. Will there be other organizations present during this event conducting the same screenings? *

Yes

2. Will this event be held inside? *

Yes

3. If inside, will tables (2) and chairs (6) be provided? (we can bring ours if necessary) *

Yes

(blood sugar, blood pressure, cholesterol, BMI)

4. If outside, is there enough space for the Mobile Health Unit to park? *

Yes