Vendor Lunch Request – Hillside Medical Group

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Representative Information

First Name * Please enter your first name.

Last Name * Please enter your last name.

Company Name * Please enter your company name.

Product / Specialty * Please select a category.

Email Address * Please enter a valid email address.

Phone Number * Please enter a valid phone number.

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Location & Date

Select Location * Please select a location.

Allowed Days:

Preferred Date * Please select an allowed lunch day for this location.

Alternate Date (optional) Please select an allowed lunch day for this location.

Estimated Attendees * Approximate number of staff attending Please enter the estimated number of attendees.

Arrival Time All vendor lunches are scheduled at noon.

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Lunch & Presentation Details

What Will You Be Providing? * Please describe what you will be providing.

Topic / Purpose of Visit * Please describe the purpose of your visit.

Special Notes or Requests (optional)

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Agreement & Submission

I understand that this request is subject to review and approval by Hillside Medical Group administration. I will receive an email confirmation once my request has been approved or denied. I agree to abide by the scheduling policies of each location.

I further acknowledge that vendor lunches are provided for educational and informational purposes only. No solicitation, inducements, or kickbacks of any kind are permitted in connection with this visit or any future interactions with Hillside Medical Group staff or providers. Any such activity — including but not limited to offering gifts, incentives, or compensation in exchange for prescribing, purchasing, or referral decisions — is strictly prohibited and will be reported to the appropriate federal, state, and/or regulatory authorities, including but not limited to the Office of Inspector General (OIG) and applicable state licensing boards.

You must agree to the terms before submitting.

Your request will be reviewed by our administrative team.