FREE Cardiac Patient Gift Bags
Request Form


Please complete and submit this form if you would like to request FREE Cardiac Directions® gift kits.  All information must be completed in order for you to qualify.
Only cardiac rehab facilities, stroke centers and physician practices based in the continental United States qualify for this program.

1.  Office Phone Number (with area code)
3.  What is your shipping address?  (P.O. Boxes are not allowed for kit shipments.)
Dept Name
(if applicable)
Facility Name
Zip Code
2.  What is your mailing address?
mailing & shipping address are identical (as listed above)
Dept Name
(if applicable)
Facility Name
Zip Code
4.  Email address (Used ONLY for important communications about our program.)
4a.  Secondary email address
5.  Description of your healthcare services. (mark all that apply)
Cardiac Rehab
Stroke Rehab
Cardiac Cath Lab
Cardiac Surgery Center
Cardiologist working with cardiac rehab
Cardiologist not working with cardiac rehab
Other Doctor: what specialty?
6.  Who should we contact at your location concerning administration
     of the program?
Main Contact: Name    
Job Title


Alternate Contact: Name    
Job Title
7.  Please indicate how many new patients enter your program or office
     in an average month, for whom you'd like to receive free gift kits.
new patients per month
Questions 8 & 9 apply to Cardiac Rehabs or Stroke Centers ONLY (If you are applying for a physician's office, please skip to question 10.)

8.  For which programs does this number of patients apply? 
(check all that apply)
In-Patient (Phase I) 
Out-Patient (Phase II & III)
Stroke Center
Misc./Other Cardiac Rehab Format Please describe.
9.  Is there another cardiac related unit in your
     hospital that might see patients you miss?
Who is that contact person?

Question 10 is for Physician Offices ONLY (If you are applying for a cardiac rehab, please skip to question 11.)

10.  How many physicians work at this office location? 
number of physicians
11.  Are there any types of product samples you find objectionable, which
       would cause you to reject the program? 
All generally acceptable 
OTC medications
Other (please specify)
12.  How did you hear about this program? (check all that apply)
Received info in the mail
Magazine/professional journal ad or listing
Internet listing/received email announcement
Friend/colleague referral
Professional conference
Other (please specify)
13.  Patient kits are packed with approx. 70-100 kits per carton
       ... how many cartons would you like per shipment?

       (Note: Be sure you have adequate storage space. Kits arrive in cartons that are about the same
        size box that copy paper comes in.)
cartons per shipment
14.  OPTIONAL: If you have any questions, comments, or special
        instructions, please note those here:
Our facility would like to receive the free Cardiac Directions® Program. 
We agree to distribute only one gift kit per cardiac patient.
Your Name
Job Title


The Dialogue Company reserves the right to limit distribution quantities,
and remove any facility from the program that it deems necessary.


Copyright © 2002- by The Dialogue Company. All rights strictly reserved.

The Dialogue Company Logo Cardiac Directions® Program
The Dialogue Company
106 Straube Center Blvd.
Pennington, NJ 08534

Fax: (609) 737-6927
Phone: (800) 972-7994

Free Cardiac Directions Patient Kit