Affiliate Referral Program

Affiliate Referral Submission Form
Referring Company and Contact Information:

Help us connect with you to track your referral and ensure you receive your $500 invoice credit and $100 appreciation gift!
Name of Referring Company (to receive $500 credit):*
Name of Referring Employee (to receive appreciation gift up to $100):*

First NameLast Name
$100 Amazon Gift CardComplimentary meal for the clinic, up to $100Speak to our Sales Rep for additional options
Referring Employee Email Address: *
example@example.com
Referring Employee Best Contact Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Payout Process Reminder: If your referral leads to the successful placement of one or more Virtual Health Associates (VHAs) with a new client, you will receive a $500 reduction on your next invoice after the VHAs have been deployed for 30 days. Additionally, the referring person will receive a special appreciation gift valued at up to $100 once the VHAs have been successfully deployed for 30 days with the new client.
Referred Company and Contact Information:

Who Are We Contacting to Share the Benefits of Eleos?
Name of Referred Company (who we're contacting):*
Best Point of Contact (POC) Name:*

First NameLast Name
What is the POC's title/position within the referred company?
POC Email:*
example@example.com
POC Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Scribe (Virtual Clinic Optimizer)Medical AssistantReferral CoordinatorFront Office/Patient RegistrationMedical Records/Documentation ManagementPrior Authorizations/Insurance EligibilityValue Based Care
Please provide any notes that would be helpful for our team when reaching out to this referred organization:
Should be Empty:

Affiliate Referral Submission Form

Referring Company and Contact Information:

Referred Company and Contact Information: