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Request Patient Samples

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 would like to download and fill out our printable Sample Request form, click here.
If you are not a medical professional and would like to sign-up for information, coupons and other offers, please click here.

Required Fields indicated by *

Name *

First Name *

Last Name *

Practice Name *

Practice Address *

Address 1 *

Address 2 (Building, Suite Number, etc.)

City *

State *

Zip *

Phone *

Email *

Confirm *

The following product samples are currently available for Medical Professionals to provide to their patients:

RepHresh Vaginal Gel – For your patients with vaginal pH and odor issues.
RepHresh Vaginal Gel is clinically shown to maintain healthy vaginal pH and eliminate odor. Healthy pH can help reduce risk of vaginal issues. RepHresh Gel samples are available in a 1 applicator sample pack. Instructions and coupons are enclosed inside each sample pack.
RepHresh Pro-B Probiotic – For your patients who want to maintain their feminine health with just 1 capsule a day.
RepHresh Pro-B is 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.* RepHresh Pro-B samples are available in a 7-Day Starter Pack. Instructions and coupons are enclosed inside each sample pack.
Replens Long-Lasting Vaginal Moisturizer - For your patients suffering from vaginal dryness
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. Replens samples are available in a 1 applicator sample pack. Instructions and coupons are enclosed inside each sample pack.
Pre-Seed Fertility Friendly Personal Lubricant - For use when trying to conceive
Pre-Seed is clinically show to be "sperm safe". Pre-Seed mimics natural fertile fluids and allows swimming sperm to move freely. Provides Antioxidant Support and is pH balanced to match fertile cervical mucus and pH of sperm.

Please select which product samples you would like to hand out to your patients.

I would like to receive patient samples for all four products:
RepHresh Gel, RepHresh Pro-B, Replens and Pre-Seed.

Or, if you only need to reorder samples of one or two items at this time, please check the box(es) below to indicate the samples you require.

	RepHresh Vaginal Gel
	RepHresh Pro-B Probiotic
	Replens Long-Lasting Vaginal Moisturizer
	Pre-Seed Fertility Friendly Personal Lubricant

I would like Brochures and Coupons Only:
I would only like to receive brochures and coupons, no patient samples are needed at this time.

Number of Medical Professionals in practice *

(Please put in a number)

I confirm I am a licensed medical professional or an official representative of the medical practice.

Question or Comment

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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.

Printable Sample Request Form

Download and fill out our printable Sample Request form and Send your Request to us by email, fax or mail.
Note: Attach completed form to email and enter "Sample Request" in the subject line.

Fax to:
319.393.3494
Attention: Sample Request

Mail to:
Lil' Drug Store Products, Inc.
Attention: Sample Request
P.O. Box 1883
Cedar Rapids, IA 52406

* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.