Request Samples and Coupons Healthcare Professionals Request Form Request free samples or join our Regular Girl affiliate program. *Required Name* First Last Email* Phone NumberJob TitlePractice / Facility NamePractice WebsitePractice Address* Street Address Address Line 2 City State State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Same as shipping address?YesNoShipping Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Professional Credentials*Please SelectMD / DONPPARDNRNSLPOtherPractice Area*Please select your area of practice and we'll send samples and brochures with coupons that match the needs of your patients.Please SelectOncologyPediatricBariatrics / Weight ManagementGastroenterologyMedical Nutrition / Clinical DieticianIntegrative / Complimentary MedicineRenalPrimary Care / Family MedicineHealth & WellnessSurgerySports NutritionOtherProducts 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. CommentsYes, I would like to join the Regular Girl Healthcare Professional Affiliate programHelp your community get on a more regular path and boost your income by becoming a Regular Girl affiliate. Affiliates earn a 10% commission on all orders made through their link or using their custom coupon code. They also receive additional resources including images, recipes and downloadable resources. Yes, I would like to join 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 Yes, I’d like to learn more about Professional wholesale opportunities This iframe contains the logic required to handle Ajax powered Gravity Forms.
