Please submit this form if you would like to apply for the FREE HealthStart program. All information must be completed in order for you to qualify. Only healthcare providers based in the continental United States qualify for this program.

Hint: Use your “tab” key or mouse pointer to move to each field. Do not press your “enter” or “return” key, because that will submit a blank form.

Exact contents of packs will vary.


Contact Person: (Note: Wellness packs will be shipped to the attention of the contact person. Please do not use
commas when typing this information.) (Email is used ONLY for important communications about our program)
First Name:
Last Name:
Job Title:
Phone Number: (with area code)
Shipping Address:
(Note: Please do not use commas in your address. P.O.
Boxes are not allowed for shipments.)
Clinic Name:
Address 1:
Address 2:
Zip Code:
3. Mailing Address:
    Shipping & mailing address are identical
Clinic Name:
Address 1:
Address 2:
Zip Code:
Please indicate how many patients you see in an average month for whom you would like to receive free
wellness packs
  Patients per month
Please specify the type of wellness pack you would prefer.
Ones in which...
Everything is Included (All sponsor products are acceptable)
OTC Meds are not present
Vitamins/ supplements are not present
Other items are not acceptable (please specifiy)
How did you hear about this program? (Check all that apply)
Received info in the Mail/Email
Magazine/professional journal ad or listing
Newsletter/eNewsletter (Ex: "Retail Clinician")
Internet listing
Friend/colleague referral
Notified by our headquarters
Professional conference (please specify)

Other (please specify)
Do you have a storage problem?
If YES, we can only accept boxes per shipment.
(Cartons are approximately the size of a large microwave oven
box; as large as: 23" long x 15" deep x 15" tall.)
Please indicate whether you work in a: (Check all that apply)
Retail Clinic
Doctor's Office
Other (please specify)
If you work in a retail store location, what type of store is it? (Check all that apply)
Supermarket / Grocery Store
Self-Standing Drugstore
Large Discount Store (Walmart, Kmart, Target, etc.)
Name of retail partner store
Comments (optional)
If you have any questions, comments, or special instructions, please note them here:
We / I would like to receive the free HealthStart® Program. We / I agree to distribute only one wellness pack per patient, free of charge. We / I agree not to sell or distribute wellness packs in any other manner.
Your Name:
Job Title:
QUANTITIES ARE LIMITED, therefore all applications will be screened to determine whether they meet eligibility criteria. The Dialogue Company reserves the right to limit distribution quantities, and remove anyone from the program that it deems necessary.