BROCHURE REQUEST FORM

Please enter the information requested and then click on the “Submit” button. The fields marked with * are required. All brochures may be downloaded and printed from your Provider Resources page. For large brochure quantities, please call 888-719-9990.

"*" indicates required fields

DOCTOR's Name*

First Last

Clinic Name*

Clinic Phone*

DOCTOR's Email*

Enter Email Confirm Email

To ensure we have the most up-to-date information, please provide your preferred mailing address for item delivery.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please select the types of brochures you need below.*

CHUSA Patient Brochures

CHUSA Plus Brochure

Alaska Patient Brochures

Spanish Patient Brochures

BROCHURE REQUEST FORM

PROVIDERS

Disclosures