Reverse Medical — Referral Reward Claim
Use this form to claim your reward after successfully referring a new patient to Reverse Medical or leaving us a review. Our team will verify your submission and contact you within 2 business days to apply your reward.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which reward are you claiming?
*
Please Select
2 Free Months of TRT Program
Free Power Up Medication Order
$50 Power Up Voucher (Written Review)
2 Free Months + $50 Off Power Up Code (Video Testimonial)
Name of the patient you referred
*
Referred patient email or phone (helps us verify the referral)
How did you refer them?
*
Shared my referral link
Told them in person
Sent them a text or email
Posted on social media
Proof of referral or review (screenshot or link)
Upload a File
Drag and drop files here
Choose a file
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of
Link to video testimonial (if applicable)
Additional notes
Submit Claim
Should be Empty: