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ALA medica Inquiry Form

*Response to the materials request shall be limited to physicians who are considering
the purchase of any machines in the lineup.

Inquiry product requisite	Harmony seriesAccent seriesSoprano seriesOthers
Details of your inquiry optional	Input names of machines or treatment menus you are considering if any.
Facility Namerequisite
Namerequisite
Occupationrequisite	DoctorNurseOthers
Positionoptional
Medical subject optional	DermatologyAesthetic dermatologyCosmetic surgeryPlastic surgeryOrthopedic surgeryGynecologyInternal medicinePediatricsOthers
E-mail addressrequisite
Phone numberrequisite
Facility addressrequisite	Postal code address1 address2
Remarksoptional
Consent to handling of personal informationrequisite	Click here to see more information on our privacy policies. Check the box if you agree on the handling of personal information.

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