Healthcare Professionals
Sample and Coupon Request

At Orgain we're committed to helping healthcare professionals provide the very best care to their patients and clients. If you are a healthcare professional providing direct care to patients or clients, please complete the form below to make an initial request for complimentary Orgain samples and patient brochures.

If you have already placed an initial sample request using this form, please email us at to request additional samples.

Please provide your name, job title and email address here, and complete the remainder of the form with the information of the healthcare professional for whom you are submitting the request.

Complete the fields below with information about the healthcare professional.

(Please provide a physical address. We are unable to ship to PO Boxes.)

Please enter your medical license or registration #

(Please select your area of practice and we'll send samples and brochures with coupons that match the needs of your patients.)

If you were referred to this site by a colleague, please tell us who referred you: