Patient & Visitor Alert: Because flu cases are on the rise, starting February 24, children 12 and younger
will be restricted from visiting hospitals and certain inpatient facilities throughout Carolinas HealthCare System. Learn more.

Carolinas HealthCare System

Thank you for your interest in the medical coverage services at Carolinas Medical Center.

You will be contacted via email and/or phone number listed in your request with 7 days. Filing a request does not imply guaranteed medical coverage.

Please contact the Carolinas Medical Center’s Department of Sports Medicine & Special Events at 704-512-3820 if you have any immediate questions.

* Indicates required information
Today's Date: * 
Billing Information 
Organization: * 
Contact Name: * 
Address: * 
City: * 
State: * 
Zip: * 
Office Number: * 
E-mail * 
Event Information 
Name of Event * 
Date(s) of Event: * 
Start time of Event: * 
Finish Time (approx.) of Event: * 
Venue Name: * 
Venue Address: * 
Venue City: * 
Venue State: * 
Venue Zip: * 
Expected attendance:  * 
Age Range of Attendance: * 
Expected athlete attendance: * 
Age Range of Athletes: * 
Name of Contact at the event: * 
Cellular Number: * 
Medical Coverage Request 
Staff certification level requested and number personnel requested:  
Physician (MD): * 

If yes, # personnel requested: 
Paramedic: * 

If yes, # personnel requested: 
Emergency Medical Technician (EMT): * 

If yes, # personnel requested: 
Registered Nurse (RN): * 

If yes, # personnel requested: 
Athletic Trainer (ATC): * 

If yes, # personnel requested: 
Request an ambulance(s) for venue site(s): (*Required staffing of one Paramedic and one EMT*) * 

Request for Mobile Sports Medicine vehicle (non-transport): (*Minimum of 2 staff*) * 

Comments/ Questions: