OBGYN Mobile Unit Appearance Request

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Required format:

RnF5yVUKeYUI8y4wgrPbru5iH

The OBGYN Mobile Unit values every opportunity to engage with our community, and we appreciate your interest in having us participate in your event. We receive many requests throughout the year, and while we strive to accommodate as many as we can, completing the Appearance Request Form helps us understand your event's needs and determine availability.

Once your form is submitted, a member of our team will review the details and reach out in a timely manner to discuss next steps. After the review process is complete, everyone will receive a call to confirm whether the Mobile Unit will be able to attend their event or not. We look forward to learning more about your event and exploring how we might support your efforts to promote community health.

Thank you!

Today's Date

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M-D-Y

Organization/Department Name

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Event name

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Event address

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State

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Zip code (5-digit)

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Event date

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M-D-Y

Event start time

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Event end time

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First name

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Last name

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Phone number

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Email address

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Is the on site contact person for the day of the event different from the person filling out this form?

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Yes

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On site contact First and Last name

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On site contact phone number

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Target population

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Pregnant Individuals

Postpartum Individuals

Non pregnant women

Requested services

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Prenatal Care

Postpartum Care

OBGYN Check up/Annual Visit

Contraceptive Counseling

Lactation Support

Health Screening

Educational Workshops

Other

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What type of screenings are needed?

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Specify topic

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Please describe the services you are requesting

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Are language services needed?

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Yes

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Please specify language(s)

Estimated number of participants?

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Please describe the purpose any specific goals/outcomes you desire from the event.

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Is there a budget allocated to this request?

Yes

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What is the budget?

Please upload event flyer if applicable

Upload file

Will community partners be involved in the event?

Yes

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please list community partners

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