Event Medical Coverage Form Your Details Your Name * First Name Last Name Phone Number Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Event Information Event Website http:// Event Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date Required On Site MM DD YYYY Time Required On Site Hour Minute Second AM PM Date Required Off Site MM DD YYYY Time Required Off Site Hour Minute Second AM PM If more than one day please put dates and times here. Event Type * Classical Performance Country Show Motorcycle Display State Occasions New Year Celebrations Cycling / Boxing / Sports Public Exhibition Dance Event Aviation VIP Visits/Summit Night Club Other Pop/Rock Concert Marine Motor Sport Music Festival Film / TV Venue Type * Indoor Public location in streets Outdoor in confined Location, Eg. Park Overnight Camping Stadium Sports ground Temporary Outdoor Structures Other Outdoor, Eg. Festival Audience * Full Mix, in Family Groups Predominantly Young Adults Predominantly Elderly Full Mix, Not in Family Groups Predominantly Children and Teenagers Full mix, Rival Factions Past History of Casualties * Good data, low casualty rate previously (less than 1%) Good data, medium casualty rate previously (1% - 2%) Good data, high casualty rate previously (more than 2%) First event, no data Expected Numbers * This wants to be as accurate as possible, as this is the largest factor when it comes to pricing and resources on site. <1,000 <3,000 <5,000 <10,000 <20,000 <30,000 <40,000 <60,000 <80,000 <100,000 <200,000 <300,000 Expected Queuing * Less than 4 hours More than 4 hours More than 12 hours Time Of Year * Spring Summer Autumn Winter Additional Hazards * Carnival Alcohol Helicopters Motorsport Parachute Display Fireworks Stunts Water Sports None Important Event Information * Everything we would need to know to make this event as safe as possible Choose the most appropriate service model: No individual score over 1 - First Responder-led service No individual score over 2 - Paramedic or Nurse-led service No individual score over 3 - Doctor-led service Any individual score of 4 or 5 - Emergency Medicine doctor-led service Expected number of patient presentations * Very low Low Medium High Very high Expected level of patient acuity * Very low Low Medium High Very high Expected levels of drug & alcohol problems * Very low Low Medium High Very high Expected levels of violence and disorder * Very low Low Medium High Very high Do you require overnight medical cover? * Both on site options are chargeable but at different rates. No Thank you - we close Yes please - Crew change crews to stay awake Yes please - disturbability (can sleep) Please quote for * Medical Cover Medical Cover Whilst we enjoy events, we dont like standing around waiting for an accident to happen. So we get involved and use our skills to interact with your public. Would you like any of the following free services? * Free Blood Pressure Checks Public Talk about the Service CPR Demonstrations No thank you Please send any files to event@medixis.co.uk with the reference you have entered below * Please upload any plans and risk assessments. Do you require us to attend any SAG meetings? * This is chargeable. Yes No Only If required Thank you!
