• Print    Email
  • Decrease (-) Restore Default Increase (+)
  • Bookmark and Share

Invite Us to Join You

If you would like to invite a member of the Rex Healthcare team to your health fair, please provide us with the information below. When you have completely filled this form, click submit to send your request.

* Indicates required information
Name * 
Organization * 
Email Address * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Telephone * 
Event Name * 
Number of Attendees * 
Event Date *   Calendar (mm/dd/yyyy)
Event Time * 
Event Address * 
Event City * 
Event State * 
Event Zip * 
Screenings requested 
Information requested 
Premium items only 
Other information 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.