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*
How do you currently provide care/services?*

In-person sessionsOnline / Telehealth (virtual) sessionsBoth in-person and online
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

Please enter only your username (no @, no links, just the handle). Example: johndoe
Instagram
TikTok
YouTube
Facebook
Would you like to be considered for collaborations or features on our social channels?*

YesNo
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? *
Wholesale Program

We'd love to understand your buying expectations so we can tailor our wholesale pricing to your 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
Preferred Provider Program

We’re exploring a way to connect NewFlora customers with trusted providers for personalized guidance, support, and product education. As a Preferred Provider, you’d be introduced to interested customers in exchange for one free consult. Any ongoing relationship from there is entirely yours.
Would you be interested in learning more about becoming a Preferred Provider?*
Samples to request

We're happy to provide one free sample of each product. If your clinic has multiple branches, please resubmit this form for each location using a unique email (the discount works once per email).
Samples to request*

5 Piece Dilator SetPelvic WandVibrating Pelvic Wand
Source
By submitting this form, you consent to receive communications via email and phone.
Should be Empty:

Social Media Handles

Questionnaire

Wholesale Program

Preferred Provider Program

Samples to request