Contact Onsite Medical OnSite Medical welcomes the opportunity to see if we’re a good fit for the medical needs of your most valuable asset, your employees 206-536-1600 email@example.com www.onsitemedical.com Filling out this form helps us access whether we are a good fit for your business. Please let us know: Name * First Last Phone Number * Email Address * Primary Business Address Address Line 1 Address Line 2 City State Zip Code Number of Locations? * 1 2 3 More than 3 Number of Employees at Each Location 1-500501-10001001-20002001-5000>5000 Location 1 Location 2 Location 3 All Other Locations Type of Clinic You Are Interested In? * — Select — Medical Only Dental Only Medical and Dental Do You Have a Space Available to Build Your Onsite Clinic? * — Select — Yes No What is Your Timeframe for Opening Your Onsite Clinic? * 1-3 Months 3-6 Months 6-12 Months One Year or Longer Any Other Comments or Special Requests?