{"id":2422,"date":"2020-06-19T18:42:44","date_gmt":"2020-06-19T18:42:44","guid":{"rendered":"http:\/\/merzaesthetics.m3rzd3v.com\/?page_id=2422"},"modified":"2025-12-04T13:30:45","modified_gmt":"2025-12-04T18:30:45","slug":"forms-consumer","status":"publish","type":"page","link":"https:\/\/www.merzaesthetics.ca\/fr\/merzaesthetics\/forms-consumer\/","title":{"rendered":"Formulaires : Clients"},"content":{"rendered":"\n<div class=\"wp-block-group container-wrap\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wp-block-columns row is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column col-12 col-md-9 col-lg-8 text-center mx-auto is-layout-flow wp-block-column-is-layout-flow\">\n<h3 class=\"wp-block-heading col-heading\">Contact Us<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Thank you for reaching out to Merz Aesthetics.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Please select from the following options, so that we may best support you. Please contact Customer Solutions at 1-877-336-4008 to report a product complaint, adverse event, submit a product order, or for order or account-related inquiries.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Consumer and all other individuals<\/h4>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework gf-hcp-other_wrapper gform_multi_column_wrapper gform_column_count_2_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' ><form method='post' enctype='multipart\/form-data'  id='gform_5' class='gf-hcp-other gform_multi_column gform_column_count_2' action='\/fr\/wp-json\/wp\/v2\/pages\/2422' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_5_31\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_31'><span class='gform-field-label__text'>LinkedIn<\/span><\/label><div class='gfield_description' id='gfield_description_5_31'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_31' id='input_5_31' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half col-12 col-md-6 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'><span class='gform-field-label__text'>First Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half col-12 col-md-6 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'><span class='gform-field-label__text'>Last Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full col-12 col-md-4 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'><span class='gform-field-label__text'>Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_5_14' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-email gfield--input-type-email col-12 col-md-8 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_5_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_24\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full ginput_container_text input field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city ginput_container_address gform-grid-row' id='input_5_24' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_24_1_container' >\n                                        <label for='input_5_24_1' id='input_5_24_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_24.1' id='input_5_24_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_24_2_container' >\n                                        <label for='input_5_24_2' id='input_5_24_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_24.2' id='input_5_24_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_24_3_container' >\n                                    <label for='input_5_24_3' id='input_5_24_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_24.3' id='input_5_24_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_24.4' id='input_5_24_4' value=''\/><input type='hidden' class='gform_hidden' name='input_24.6' id='input_5_24_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_5_26\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_state ginput_container_address gform-grid-row' id='input_5_26' >\n                        <span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_26_4_container' >\n                                        <label for='input_5_26_4' id='input_5_26_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                        <select name='input_26.4' id='input_5_26_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' selected='selected'>Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_26.6' id='input_5_26_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/ul><ul class=\"gform_fields top_label form_sublabel_above description_above validation_above column column_2 \"><div id=\"field_5_8\" class=\"gfield gfield--type-select gfield--input-type-select col-12 col-md-6 ginput_container_text input gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'><span class='gform-field-label__text'>Topic<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_5_8' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Choose Your Topic*<\/option><option value='Business Opportunity' >Business Opportunity<\/option><option value='Aesthetics Products' >Aesthetics Products<\/option><option value='Press Request' >Press Request<\/option><option value='Merz as employer' >Merz as employer<\/option><\/select><\/div><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-select gfield--input-type-select col-12 col-md-6 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_9'><span class='gform-field-label__text'>Product<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_5_9' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Xeomin Aesthetics' >Xeomin Aesthetics<\/option><option value='Radiesse' >RADIESSE<\/option><option value='Belotero' >Belotero<\/option><option value='Ultherapy' >Ultherapy<\/option><option value='Neocutis' >Neocutis<\/option><\/select><\/div><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea col-12 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'><span class='gform-field-label__text'>Message<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='1000' data-text-counter-template='{current} of {max} max characters'><textarea name='input_10' id='input_5_10' class='textarea medium'   maxlength='1000' placeholder='How can we help?' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_30'><div class='gfield_consent_description_text' tabindex='0'>By completing this form, you consent to Merz Aesthetics Canada Ltd. using your email address and other information you provide to contact you in response to your inquiry. We may disclose the information you submit to select experts within or outside the Merz network for evaluation.<br \/>\n<br \/>\nFor more information about our privacy practices, please read our <a title=\"Privacy Policy\" href=\"https:\/\/merzaesthetics-ca.m3rzd3v.com\/privacy-policy\/\">Privacy Policy<\/a><\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_30.1' id='input_5_30_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_30\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_30_1' ><span class='gform-field-label__text'>I agree to the privacy policy.<\/span><\/label><input type='hidden' name='input_30.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_30.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> <input type='hidden' class='gform_hidden' name='gform_submission_speeds' value='{&quot;pages&quot;:[]}' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='+4P5iP+6cQnkekaendo\/930jK5U81AFLqy\/u2ZuLDTfM06GxkS1pf92sLbZvTyI8bmxWrrBlt0PbGn2YBKUgTdHKZuUYhOq47vda0AwVBAbqpzw=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n<\/div>\n<\/div>\n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Contact Us Thank you for reaching out to Merz Aesthetics. Please select from the following options, so that we may best support you. Please contact Customer Solutions at 1-877-336-4008 to report a product complaint, adverse event, submit a product order, or for order or account-related inquiries. 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