Personal Details

First Name *

Last Name *

Email *

Cell Phone Number *

For SMS notifications or follow-up

Company / Clinic Name *

Website / Social Media Link

At least one required to verify audience and influence

Promotion Information

Affiliate: What best describes you? *Check all that apply

Affiliate: What best describes you? Other write in

Affilate: How do you plan to promote the Virtual CA program? Other write in

Estimated audience reach (email list, social followers, podcast downloads, etc.) *

💬 Affiliate Agreement

Affiliate: Terms & Conditions

By checking this box, I understand that referral payouts are triggered after the referred client completes their first payment?

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or 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. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.