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Material Request Form
1
PLEASE READ:
This material request form is no longer in use.
All orders should now be placed through the Print Store by contacting your clinic director, who will submit the order on your behalf.
If you need to order custom digital or print flyers or need to order an existing flyer with added edits, please use the updated
ServiceOne Request Form link
on C6RE Connect and include as much detail as possible in your request. If you have any questions, feel free to reach out to Breanna at breannah@spineandsport.com.
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2
Let's get started!
*
This field is required.
*This is in reference to the employee receiving the order.
Tell us what role you have in the company.
I am a Physical Therapist, Physical Therapist Assistant, Business Development team member, Director, Manager, Specialist or Lead.
I am a Patient Care Coordinator (PCC), Physical Therapy Technician (PT Tech), hold any other role not listed in the first category above OR just simply need to order appointment cards
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3
Are you looking to order business cards? See below.
*
This field is required.
While PCCs & PT Techs do not receive business cards, you are provided with clinic appointment cards. These cards offer a personal touch, featuring a signature line where you can sign your name before handing them to patients. This adds a personalized element to your patient interactions.
Would you like to place an order for Appointment Cards?
YES
NO
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4
Great! We'll add these to your order
This is a preview of what they will look like
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5
Would you like to add business cards to your order?
*
This field is required.
You can add more to your order on the next slide. Please only add what you need to your order.
YES
NO
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6
Would you like to add a
wall photo
to your order?
*
This field is required.
You can add more to your order on the next slide. Please only add what you need to your order.
YES
NO
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7
Would you like to add a
name tag
to your order?
*
This field is required.
Please only add what you need to your order.
YES
NO
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8
Employee Contact
*
This field is required.
First name & Last Name. Please use sentence case -- not all caps.
First Name
Last Name
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9
Employee Credentials
*
This field is required.
Ex. PT, DPT, OTR/L, etc.
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10
Employee Position
*
This field is required.
Ex. Physical Therapist, Clinic Director, Multi-Site Clinic Director, etc.
Note:
If you are a Clinic Director, you do not need to also put Physical Therapist in this section, your credentials cover that
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11
Employee/Clinic Phone Number
*
This field is required.
Please enter a valid 10 digit
office
,
clinic
or
work-mobile
number.
DO NOT add your personal #.
DO NOT ADD YOUR PERSONAL CELL NUMBER
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12
Employee Email Address
*
This field is required.
Type slowly
, this is the email we will use to send your proof.
firstnamelastinitial@spineandsport.com
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13
Employee Clinic Name
*
This field is required.
Dana Point, El Centro North, Poway, Service Center, Etc.
Please include the full name of your clinic, Spine & Sport is not a clinic name
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14
Employee Clinic Address
*
This field is required.
To find your clinic type out: "
Spine & Sport Physical Therapy - [ your clinic name ]"
If clinic does not populate, simply type in the address manually.
Street Address
Suite #
City
Please Select
CA
Please Select
Please Select
CA
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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15
Employee Name Tag / Wall Photo Formatting
Please format your name, credentials & position title
as it would read on your name tag or wall photo
. Example: John Smith, PT, DPT Clinic Director
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16
Employee Wall Photo
READ BEFORE UPLOAD:
Please ensure you are wearing professional clothing and you are centered in the frame. Please take photos in the best lighting possible, usually outside. No selfies.
Please label your image file before uploading as 'FirstName.LastName'.If your file is not named properly, your order will be automatically cancelled
. Accepted file types: jpeg, jpg & png. Accepted file size: 1 MB - 512 MB.
Drag and drop files here
Select files to upload
Upload Headshot
File Name: firstname.lastname
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17
Notes
Please add any additional information you'd like us to know below.
ie. Is your clinic inside an LA Fitness?
Please note:
Unless otherwise specified, the centralized fax number will be on all cards
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