rep

If you have any questions, please call us at 512-553-5392.
SALES REP INFORMATION
Sales Rep*
First Name Last Name
Phone
Email*
MARKETING ITEMS NEEDED
Rack Cards
- Yes
Coupon Code on Bottom of Rack Card*
Each rep has a unique word followed by a -#. This allows us to know the rep associated. The number corresponds to the practice
Number of Rack Cards Needed*
Please enter a number from 30 to 500.
Additional Rack Cards Needed
- Yes
Coupon Code on Bottom of Rack Card*
Each rep has a unique word followed by a -#. This allows us to know the rep associated. The number corresponds to the practice
Number of Rack Cards Needed*
Please enter a number from 30 to 500.
Samples & Trial Packs
- Yes
4-page Doctor Brochures
- Yes
Number of Brochures Needed*
Please enter a number from 1 to 10.
Notes: Any Instructions?
Address for everything to be sent to
- Address on file
- New Address
New Address or Practice Address
Street Address Address Line 2 City State ZIP Code

SALES REP INFORMATION