Newspaper Ads Order Form

Please Note: in order fulfill all our client marketing requests we require a minimum of 10 working days’ notice prior to the AD deadline. If your AD is due in less than 10 working days, please contact us prior to submitting your request. You can contact us by email at


Clinic Information

* Required fields.


Contact Name:


Email Address:


Account Name:


Account Number:





Ad Information

* Required fields.


Have you booked an AD space in your publication?


If yes, when is the deadline to submit the AD to your publication?

Please provide your AD dimensions (in inches) as per your booking.

Width (inches)

Height (inches)

Please provide the name of your publication?



Please select the Newspaper Ad style and format you wish to order (choose only one): *

Beach, Convertible and Stairs Ads can be customized to multiple ad dimensions. Please contact


(Full Page)

(Full Page)

(Full Page)

Benefits (Full Page)





Benefits (Half Page)

Benefits (Quarter Page)

Event (Full Page)

Event (Half Page)





Event (Quarter Page)

Lens (Full Page)

Lens (Half Page)

Lens (Quarter Page)


Please complete your clinic information as you would like to see appear on the Newspaper Ad.


Clinic Name:







Please upload your logo
if you would like it included in the ad:

Acceptable logo formats are: .eps, ai, pdf

Would you like to include a map?


Other Details: