MARKETING MATERIALS REQUEST FORM

Please enter the requested information and click on the “Submit” button. The requested materials will be sent via US Mail at no cost to you.

Personalized QR Code Labels

Patients may now sign up for ChiroHealthUSA themselves by scanning a unique QR code in your clinic.

Countertop Standee

Place on your clinic front desk to remind patients that your practice is a ChiroHealthUSA provider.

Door
Decal

Place on your clinic front door to remind patients that your practice is a ChiroHealthUSA provider.

"*" indicates required fields

All fields are required.

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

Which assets would you like to receive?*

Personalized QR Code Labels

Countertop Standee

Door Decal

TERMS OF USE

Due to DMPO restrictions, you may only use marketing materials provided by ChiroHealthUSA. The QR code may not be used for any purposes other than those approved by ChiroHealthUSA.

Acknowledgment*

Please click to acknowledge the Terms of Use.

Acknowledged

MARKETING MATERIALS REQUEST FORM

Personalized QR Code Labels

Countertop Standee

DoorDecal

TERMS OF USE

Door
Decal