Registration FormStep 1 of 4 HTML Last Step! Please read the following Resellers Agreement and sign by typing your name in the boxes bellow. Chiropillows Resellers Agreement for Chiroflow Products By purchasing Chiroflow products you agree to sell Chiroflow via the following sales channels: - in your physical Chiropractic Clinic. - on your Chiropractic Clinic website, should you have one. - sales via other online business platform/marketplace, including but not limited to Amazon, eBay, is NOT allowed. By registering, you agree to receive emails (from time to time) about Chiroflow updates and sales promotions. You can unsubscribe at any time. I have read, understand, and agree to abide by Chiropillows Resellers Agreement. Clinic Name * Clinic Address Line 1 * 0 characters Clinic Address 2 (optional) 0 characters Suburb * State *ACTNSWNTQLDSATASVICWA Postcode * Country * Australia Clinic Phone * Clinic Website Do you consent to your clinic details being added to the "Find a Stockist" page * Yes No How did you hear about us?Sales Rep Website Email Postal Mail Magazine Ad Tradeshow Word of Mouth Australian Chiropractors Association Chiropractic Australia Australian Spinal Research Foundation Facebook LinkedIn Other Chiropractor First Name * Chiropractor Last Name * AHPRA Registration Number * First Name * Last Name * Date * Register Here User Email * User Password * Confirm Password * PreviousCreate a Chiroflow Account Submit
