CDM TV – Order Form – Clear Digital Media

Clinic Name*
Membership/Network/Clinic Group that Referred You*
Clinic Main Phone #*
Clinic Main Address*
Street Address Address Line 2 City State ZIP Code
Content Library Choice
Choose your content libraries.
Website*
Contact Name*
First Last
Contact Direct Phone #*
Contact Email*
Subscription Type*
- Monthly
- Yearly
Promo Code
Number of Subscriptions (1 per store rqrd)*
Please enter a number greater than or equal to 1.
Additional Subcription Location Information*
Please list below the additional clinic names, addresses & site contacts.
Choose your player:*
If you are going to use the desktop app, on the confirmation page will be a button to download.
- Roku
- Raspberry Pi Player
- I don't need a player, I already have a Roku TV
- I don't need a player, I am going to use the desktop app
Credit Card #*
Name on Card*
Expiration Date*
MM/YY
Billing Zip Code*
Security Code*
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Order Form