Request Samples and Coupons

Healthcare Professionals Request Form

Request free samples or join our Regular Girl affiliate program.

*Required

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

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

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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.
Comments
Yes, I would like to join 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. 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

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Healthcare Professionals Request Form

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