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Address:
112 Commerce Park Drive
Unit D & E
Barrie, Ontario
L4N 8W8
Tel:
(888) 527-3711
Fax:
(705) 719-1658
* = Required Fields
First Name:
*
Last Name:
*
Title:
MD
MO
DDS
RN
CMA
MA
LPN
Practice Name:
Specialty:
Dermatology
Plastic Surgery
Family Practice
OB/GYN
ENT
Opthomology
Cosmetic Surgery
General Surgery
Esthetician
Med Spa
Other
Email:
*
Website:
Phone:
*
Fax:
Address:
Address 2:
City:
Province / State:
Postal / Zip Code:
Country:
Canada
The United States
Do you currently own NexGen Laser products?
Yes
No
If Yes, which system?
Harmony
©
Soprano
™
Accent
XL™
How did you hear about us?
Print Ad
Web
Direct Mail piece
Fax
Invitation
NexGen Lasers Sponsored Event
Trade Show
From a friend/referral
Other
If other, please specify:
I am interested in:
Hair Removal
Laser360
Skin Tightening
Body Contouring
Wrinkles and Rhytids
Attending an NexGen Lasers Workshop
Attending Advanced Training
Patient Information
Clinical Information
Employment Opportunities
News Letter
Product Interest:
Harmony
©
Soprano
™
Accent
XL™
Action Required:
Please have an NexGen representative contact me.
Please contact me to arrange an on site demonstration.
Please send me additional information via US mail.
Other (please explain in comments field).
Contact Preference:
Phone or Email
Phone
Email
I am new to NexGen Laser products and technology.
I am familiar with NexGen Lasers but would like additional information.
I am currently working with a NexGen Lasers representative.
Comments
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