Associate Advertising Application Form
Clinic Name:
*
Clinic City and State:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinic Instagram Handle (If you have one):
Salary
*
Salary
*
Technique(s):
*
Length of Average Appointment:
*
Number of hours a week:
*
2-3 Sentences about your clinic, maximum of 45 words:
*
How to contact:
*
Please upload 2 images to be used for your advertisement.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Your application is not fully submitted until we’ve received payment.
Plan Options:
*
prev
next
( X )
1 Month Plan
1 month of associate advertising in your selected month.
$
400.00
Select Month
June
July
August
2 Months Plan
2 consecutive months of associate advertising in your selected back-to-back months.
$
650.00
Select Month
June - July
July - August
August - September
3 Months Plan
3 consecutive months of associate advertising in your selected back-to-back months.
$
800.00
Select Month
June - August
July - September
August - October
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
Should be Empty: