Request for Clinical Support

Request for Clinical Support
We firmly believe that product quality, safety and education is the key to maintaining your trust. Thank you for reaching out to us!

The submission of this form will create an electronic request for Clinical Support and will be responded to within two (2) business days.

To better assist you, please have the following information available for upload with this form:
- Patient before and after photographs (if applicable)
- Any photos of the threads and thread pouches in question (if applicable)
- Any relevant photos of the specific Event (if applicable)
- A copy of the treatment record (if applicable)
- A copy of the Patient's History and Physical file (if applicable)
Injector's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Account Name*
Location*

CityState
Sales Partner*
Are you requesting support for a thread treatment that has already been completed?*

YesNo
If yes, please list the date of the treatment.

MonthDayYear
Date
If yes, please list the thread type(s) and lot number(s) used.
If No, please list the threads in which you are wanting to discuss.
Age of the patient at the time of treatment:
Patient Gender
Patient's Weight
Description of relevant patient history, including preexisting medical conditions.
Please provide as much detail to your request for support here:*
What time of day is best for us to reach you?*
What method of contact do you prefer?*
Please indicate the following media available for review:

Patient History & Physical FilePatient Before & After PhotographsOther
Please upload your media file(s) here:

Browse Files

Cancelof
Please upload your media file(s) here:

Browse Files

Cancelof
By agreeing to this document, I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the evaluation of this Event. I consent to the use of this electronic signature in lieu of an original signature on paper.

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