Information Request Form

Medical Professionals may order patient samples and information about our products for office-use. Simply fill out the form below. We do not automatically send out samples on a regular basis. Please reorder as needed. All the information you provide will be kept strictly confidential.

If you are not a medical professional and would like to sign-up for information, coupons and other offers, please click here.

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Name *

First Name *

Last Name *

Practice Name *

Practice Address *

Address 1 *

Address 2 (Building, Suite Number, etc.)

City *

State *

Zip *

Phone *

Email *

Confirm *

Which of the following product samples would you like to hand out to patients?

	*RepHresh Feminine Health Kit which includes:* RepHresh Vaginal Gel - 1 Applicator: Clinically shown to maintain healthy vaginal pH and eliminate odor. Healthy pH can help reduce risk of vaginal issues. RepHresh Brilliant pH Tampons - 5 Count Pack: Clinically shown to reduce the usual vaginal pH increase during a woman’s period. Active ingredients, L-Lactide and Citric Acid, maintain a normal pH (3.5-4.5) throughout use. RepHresh Pro-B Probiotic - 7-Day Starter Pack: Clinically shown to balance Yeast & Bacteria to maintain feminine health. 1 capsule per day, taken orally, provides urogenital strains of healthy probiotic lactobacillus clinically shown to colonize the vagina to help maintain vaginal flora in a normal range. A patient-friendly brochure with product information and coupons. Full product usage instructions are provided within each product sample.
	*Replens Long-Lasting Vaginal Moisturizer:* For your patients suffering from vaginal dryness, Replens samples are available in a 1 applicator sample pack. Instructions and coupons are enclosed inside each sample pack. Replens is a clinically tested, long-lasting moisturizer that helps replenish vaginal moisture and rejuvenate dry vaginal cells. Replens provides immediate and long-lasting results.
	*Brochures and Coupons Only:* I would only like to receive brochures and coupons, no patient samples are needed at this time. Please Choose which type of Brochures you would like:

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By entering the code you see in the box, you help us prevent automated registrations. This reduces system load and ensures better performance of our services. More Information

Submit Your Sample Request

Thank you for including Replens and RepHresh Brands as
part of your options for quality patient care.

Learn more about other RepHresh products:

Eliminates Feminine Odor

Try RepHresh and take control! RepHresh Gel is clinically shown to maintain healthy feminine pH. RepHresh Gel eliminates odor and relieves minor feminine discomfort.
Learn More

Balances Yeast & Bacteria

Yeast and bacteria are naturally present in your body, and it is important they stay in balance. With just one capsule per day, you can take control of your feminine health.
Learn More

Information Request Form

Learn more about other RepHresh products:

Eliminates Feminine Odor

Balances Yeast & Bacteria

About Brilliant

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