Ambassador Application

First Name

Last Name

Phone *

Address

Street Address *

City *

State *

Country *

Postal Code *

Email *

What type of community do you primarily influence? *

School/University *

Approximately how many people would you say trust your recommendations regularly?

If you are a content creator, please give us more specifics in the questions below:

Primary Platform

Approximate Follower Count

Have you worked with brands before ?

If yes, please list the brands and type of partnership

TikTok Username

Instagram Username

YouTube Channel URL

X (Twitter) Username

Facebook Profile or Page URL

Pinterest Username

Why do you want to represent ChatRx?

If someone asks you for medical advice in your social media comments, how would you respond?

I understand I receive my commissions only when the first paid visit is completed, not based on prescriptions or outcomes.

By checking this box, I consent to receive non-marketing text messages from ChatRx about Any Specific Campaigns realting to your association. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from ChatRx at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.