Institutional Partner Application

First Name *

Last Name *

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Postal Code *

Business Name *

Brand Logo

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Brand Colors

Point Person Name and Title/Role

Business Website

Organization Type *

School Subcategories *

NCPDP *

Number of Locations *

How would you like to partner with ChatRx? (Choose all that apply) *

Approximate number of customers or cilents you serve *

By checking this box, I consent to receive text messages from ChatRx regarding my partnership, campaign updates, and program communications. 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.