First Name *

Last Name *

Phone *

Email *

What type of community do you primarily influence? *

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

Why do you want to represent ChatRx in your community? *

If someone asks you for medical advice, how would you respond? *

I understand I receive my bounty only after the first paid visit is completed, not based on prescriptions or outcomes. *

I Understand

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Community / Campus Ambassador Application