J&J MedTech

If you have a specific Medical Information Request, please use this Medical Information Request form instead of this form, so that your request can be correctly managed directly by our Medical Affairs team.

Title *

Salutation *

First Name *

Last Name *

E-mail Address *

Mobile Phone Number (Include country code) *

Country *

Preferred Language

Other Country *

Hospital Postal Code / City *

Hospital Name *

Job Title *

Product Platform *

Primary Product of Interest *

Specialty *

Procedure *

Other Procedure *

Procedure Number per Month *

Type of Interest *

Other Type of Interest *

Additional Comments *

* Fields are required

The personal data collected on this form, will be used to validate your request & also manage our relationship with you. Where you have provided your consent we will use your email address and/or phone number, to provide you with information about our medical products, services, and scientific information, and information about local and/or international medical events. Your personal data maybe be transferred to countries outside of your country of residence, including the United States, which may provide for different data protection rules than those in your country. For more information about Johnson & Johnson privacy practices and how it collects, processes, discloses, and retains your personal data, please read our Privacy Policy.

Yes

I would like to receive medical products, services & scientific information. *

Yes

I would like to receive information on local and international medical events. *

My communications preferences are:

SMS

Phone

By submitting this form, I hereby confirm that I am not reporting any adverse event and/or product quality complaint related to any of the Johnson & Johnson MedTech Companies. If you do have an adverse event and/or product complaint that you wish to report, please contact your local Sales Representative or Customer Service Team.

Please email us if you experience any technical issues with your submission