Physician Sign-up Form
Fields marked
*
are required for submission
*First Name
*Last Name
*Position
email
*Clinic Name
*Clinic Phone
*Clinic Fax
Address 1
Address 2
City
State
Zip Code
Physician UPIN
Comments
How did you hear about RollerAid?
(This information is optional but will help us with out marketing of RollerAid.)
Clinic
Physician Recommendation
email
Current RollerAid User
Internet Search
Mailing
Trade Show
Other:
How many patients do you see per month to whom you might prescribe a RollerAid
1-5
6-10
over10
Which items can we send you?
Brochure Packet (full-color, tri-fold brochures)
Holder for counter, desk or wall (includes brochures)
Prescription Pad (25 sheets per tablet)
These items are also available to download on our
Forms page
