Request Samples

Applicant Info*

First NameLast Name
Credentials*
Are you currently registered for our referral program or do you intend to?*
Business Email*
example@example.com
Clinician Mobile Phone Number*
(Necessary to process sample requests and communicate important delivery information)
Business Name*
Business Website*
Where are you based?
Business Address

Street Address

Street Address Line 2

CityState

Zip Code
Business Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Shipping Info

My shipping address is the same as my business address.
Shipping Address

Street Address

Street Address Line 2

CityState

Zip Code
Shipping Address*

Street Address Line 1

Street Address Line 2

CityState

Zip CodeCountry
Social Media Handles
Instagram
TikTok
YouTube
Facebook
Questionnaire
How did you first hear about NewFlora?*
Tell us about your patient demographics.*
In an average month, how many new patients with pelvic pain do you see?*
How often do you see patients before or after gender affirmation surgery?*
In an average month, how many new patients with urinary incontinence do you see?*
In an average month, how many new patients with Interstitial Cystitis (IC) or Painful Bladder Syndrome (PBS) do you see?*
In an average month, how many patients do you recommend vaginal dilators to?*
In an average month, how many patients do you recommend a pelvic wand to?*
If you like our samples, would you be interested in selling NewFlora products in your clinic? *
"Become A Reseller" Program

We would love to know your buying expectations to help us cater our wholesale pricing to you and your business's needs.
5 Piece Dilator Set*
Expected Order Quantity
Expected Order Frequency
Pelvic Wand*
Expected Order Quantity
Expected Order Frequency
Vibrating Pelvic Wand*
Expected Order Quantity
Expected Order Frequency
Samples to request

We are happy to provide one free sample of each of our products. If your clinic has multiple branches and you would like samples sent to each one, please fill out this form again providing the relevant addresses for each branch. (The discount will only work once per email so please be sure to use a unique email for each application).
Samples to request*

5 Piece Dilator SetPelvic WandVibrating Pelvic Wand
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Social Media Handles

Questionnaire

"Become A Reseller" Program

Samples to request