Newspaper Insert Order Form

 

Clinic Information

* Required fields.



 

Contact Name:

*

Email Address:

*

Account Name:

*

Account Number:

*

Phone:

*

 

Newspaper Insert Information

* Required fields.


   

When would you like to have your insert distributed?
(Please plan 6-8 weeks in advance in order to allow time for customization, print distribution of inserts)

*

Will your newspaper insert be promoting a special event?
i.e. Open House, etc.

*

If yes, please provide the date of the event:

Would you like Phonak to arrange printing and delivery of your newspaper insert? (Alternatively clinics can arrange printing with a preferred printer and distribution through their local newspapers)

*

 

Would you consider sharing the insert with other Lyric certified clinics
in your area? (If Yes, pricing would then be equally divided amongst participating clinic locations)

*

 

 

 

 

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


       

Lens (4 Page)

View Sample

Benefits (Double-sided)

View Sample

 

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


   

Clinic Name:

*

Address:

*

Telephone:

*

Website:

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?

*

Event Date? (if applicable):

Other Details: