Flyer Distribution Form Name * First Name Last Name Email * Subject * Which hospital(s) and/or clinic(s) will you be distributing flyers? * When will you be distributing flyers? * MM DD YYYY How many copies do you need? * Where would you like to pick up the flyers? * Please indicate the name and address of the printing service company of your choice. Please verify this location accepts electronic printing orders prior to completing this form. When would you like to pick up the flyers? * MM DD YYYY Additional Comments: Thank you for your interest! Our hospital coordinator will get back to you shortly.
