Request Samples and Coupons

Healthcare Professionals Request Form

Request free samples or join our Regular Girl affiliate program. This program is only available to those in the U.S. or U.S. territories.

*Required

Name*
First Last
Email*
Phone Number
Job Title
Practice / Facility Name
Practice Website
Practice Address*

Street Address Address Line 2 City U.S State ZIP Code
Same as shipping address?
- Yes
- No
Shipping Address

Street Address Address Line 2 City State ZIP Code
Professional Credentials*
Practice Area*
Please select your area of practice and we'll send samples and brochures with coupons that match the needs of your patients.
Products I'm interested in (select one or more)
- Regular Girl Original ~ A synbiotic blend of prebiotic fiber and probiotics that help support a healthy digestive balance, so you can feel your best from the inside out.
- Regular Girl Wellness ~ A blend of organic cranberry, prebiotics and probiotics that help promote urinary tract health while also supporting digestive balance, all without any added sugar commonly found in cranberry juice.
- Sunfiber® GI ~ The same tummy-friendly prebiotic fiber and probiotic blend as Regular Girl, packaged in convenient stick packs for every man, woman and child.
Comments
Yes, I would like to learn more about the Regular Girl Healthcare Professional Affiliate program
Help your community get on a more regular path and boost your income by becoming a Regular Girl affiliate or wholesale program.
- Send me information about the Regular Girl Healthcare Professional affiliate program
Please read the terms and conditions.
terms and conditions*
- By checking this box, I hereby confirm that I have read and agree to the terms and conditions of this program.
Examples of allowable claims and statements.
By checking this box, I agree and understand that any reference to non-allowed claims, comments or statements within my Affiliate Content may result in immediate termination of my Affiliate status.*
- By checking this box, I agree and understand that any reference to non-allowed claims, comments or statements within my Affiliate Content may result in immediate termination of my Affiliate status.
Paypal Email*
Yes, I’d like to learn more about professional wholesale opportunities
- Send me information about Professional wholesale opportunities
Name
This field is for validation purposes and should be left unchanged.

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