Medical Information Request Form Request medical information Please submit your medical inquiry about Mineralys products, trials, and research using the medical information request form below Name of Requesting Healthcare Professional * First Name Last Name Type of HCP Investigator Nurse Nurse Practitioner / Physician Assistant Pharmacist / Pharmacy Technician Physician Other Communication Method * Email MSL Mail Phone Call Email * Phone Best time to contact (if phone) Hour Minute Second AM PM Admin Contact Information (if preferred) Institution Name/Practice Name Institution/Practice Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Inquiry Text * Acknowledgement * *I certify that I am a licensed healthcare professional and that this medical information request was not solicited in any way by Mineralys personnel. I understand that any reprint or other copyright protected materials provided to me by Mineralys may be reportable as a transfer of value under the US Physician Payment Sunshine Act or applicable state transparency laws. ACCEPT Thank you! You will receive a response within 7 days.
