Merz Aesthetics

Submit a medical information request

Please fill out the form below or take a picture of your business card in order to submit your medical information request to the EMEA Medical Affairs Team.
(The fields marked with * are mandatory fields.)

First Name*

alright.

First name is required

Last Name*

alright.

Last name is required.

Upload business card

Title

City*

alright.

Please enter a city

Country*

alright.

Please enter a country

E-Mail*

alright.

Please enter a correct email address

Telephone

alright.

Please enter a correct phone number

My speciality is:*

Dermatologist

Aesthetic Physician

Plastic Surgeon

My request is about:

Bocouture/Xeomin
Belotero
Radiesse

Ultherapy
Other

My request / question

I confirm that I have read and understood the Privacy Policy and would like to be contacted by a Merz Aesthetics representative or distribution partner. Please note that depending on your location it may be necessary to forward your request to a Merz Aesthetics representative or distribution partner outside the European Union/European Economic Area.

alright.

Please accept the privacy policy.