Submit Clinic for Approval

Once your form is submitted, a team member will confirm if your city is available. If it is, you’ll receive an email with a secure payment link for the option you choose. Please complete payment within 24 hours—spots are only reserved during that window.

Back On Trac National TV Campaign – Clinic Enrollment Form

Secure your spot in the Back On Trac National TV Awareness Campaign airing daily on FOX, NBC, ABC, Tubi, and more.

This 3-month campaign launches in October 2025 and spots are limited, assigned strictly on a first come, first serve basis.

👉 Submit your clinic details today to lock in your city and gain priority access before the campaign goes live.

If your city is available, we will send you a secure payment link to complete your enrollment.

Address

Street Address

City

State

Country

Postal code *