Health Media Syndicate

Campaign Collaboration Inquiry

Please complete this form to learn more about getting involved in a Campaign Consortium.  Groups are created on demand and based on shared interest.  This is an information request form only and does not imply participation.
* Indicates required information
Healthcare Organization 
Company Name * 
Company URL 
Contact * 
Delivery Address 
City 
State 
Zip 
Country 
Telephone * 
Email * 
Provider Type 




Designated Market Areas and Campaign Focus 
Please list your DMA(s) by name(s) and state 
Describe the focus of the campaign that you wish to produce: * 
What media types would you like to include? 




Additional comments 
 

Forward the URL above to others that you may wish to involve in a media consortium!