Clinician Samples

Clinician Samples

Check out our products and show them to your patients in person!
NOTE: We are currently only able to offer free samples to clinics based in the U.S. If there is a required field you don't have a response for, please give a brief reason the field doesn't apply to you.
Applicant Info*

First NameLast Name
Credentials*
Are you a NewFlora affiliate marketer or do you intend to become one?*
Business Email*
example@example.com
Business Phone Number*
Please enter a valid phone number.
Registered Business Entity Name*
The legal name of your business that is registered with the state.
DBA Name (Doing business as)*
The name your patients know your business as, or the name you use for marketing.
Business Website*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Shipping Info

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

Street Address Line 1

Street Address Line 2

CityState

Zip Code
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. (The larger the order, the higher the discount we are able to offer.)
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
Clinician Samples Hidden Tag
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Clinician Samples

Social Media Handles

Questionnaire

"Become A Reseller" Program

Samples to request

Clinician Samples

Social Media Handles

Questionnaire

"Become A Reseller" Program

Samples to request

Get $5 off your first order.