Request Samples and Coupons

Name*

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Email*

Phone Number*

Job Title*

Where do you practice?*

Where do you sell products in your practice?

Practice / Facility Name*

Practice Website*

Practice Address*

Street Address Address Line 2 City U.S State ZIP Code

Same as shipping address?*

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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.

Do you prescribe in your practice?*

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Do you use Fullscript?*

Yes
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Do you offer samples and/or coupons directly in your practice?*

Yes
No

Do you have a social following?*

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List web urls and/or social handles

Do you have interest in a continued education webinars and courses?*

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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.

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