Thank you for your interest in the EVOLENCE® Experience Rebate. Eligibility for rebate on EVOLENCE® treatments performed in 2008 has expired. Please be sure to check out our rebate program for qualifying EVOLENCE® treatments received in 2009.

Welcome to THE EVOLENCE® EVOLUTION.

EVOLENCE® Sticker Example
Make sure to send the sticker from the EVOLENCE®
box that was used for your treatment.
Enter the LOT # as shown below
Why do we ask this?
EVOLENCE® respects your privacy. However, in order to help ensure that we are not collecting personal information from children under 13, we need to verify using your birthdate. This is pursuant to the requirements of COPPA (Children's Online Privacy Protection Act) as regulated by the FTC.
EVOLENCE® Sticker Example
Make sure to send the sticker from the EVOLENCE®
box that was used for your treatment.
EVOLENCE®

Please complete all requested information below before submitting your rebate request. The information you provide will be used by Ortho Dermatologics or third parties contracted by Ortho Dermatologics to send your rebate check and for auditing purposes.

By submitting this information, I understand that:


*Required Fields for Rebate Request
*Physician's name  
*Practice Location (city)  
*Practice Location (state)  
*Lot Number from Sticker Click here to view a sticker example.
* Injection Date
, 
* First name
* Last name
* Street address
Additional address Apt. No.
* City
* State
* Zip Code
* E-mail Address
Daytime phone number
* Birthdate
, 
* Male Female
Yes, I would like to receive more information about EVOLENCE® and future communications and promotional offers from EVOLENCE® and other Ortho Dermatologics products and its contracted third parties. To stop receiving additional communications, please contact us as specified in this website’s Privacy Policy.

Tell us about your EVOLENCE® Experience

*How satisfied are you with your EVOLENCE® treatment?
Highly satisfied
Satisfied
Not Satisfied


*How would you describe the results of your EVOLENCE® treatment? (Check all that apply)
Noticed an immediate improvement
Appeared natural-looking
Looked refreshed
Looked like myself, only better
Did not notice an improvement


*Would you recommend EVOLENCE® to a friend?
Highly recommend
Recommend
Not likely to recommend


*How did you hear about EVOLENCE®?
Doctor
Online
Beauty Magazine
Radio
Direct Mail
Friend/relative
Email
Other


*Prior to your EVOLENCE® treatment, which of the following nonsurgical physician-administered procedures have you experienced? (Check all that apply)
Chemical peels
Laser treatments
Dermal filler (such as RESTYLANE®, JUVEDERM®)
BOTOX® Cosmetic
Other
I have not previously had any other procedures


*If you have previously used another dermal filler, how would you compare your EVOLENCE® Experience?
My EVOLENCE® Experience was significantly better
My EVOLENCE® Experience was somewhat better
My EVOLENCE® Experience was about the same
My EVOLENCE® Experience was less positive
I have not previously used a dermal filler


*How likely are you to choose EVOLENCE® for your next filler procedure?
Highly likely
Likely
Not likely


QUESTIONS? Call 1-800-EVOLENCE
By submitting your EVOLENCE® Experience, consumer consents to the use of this information for market research and promotional purposes without further compensation, or notice to you, except where prohibited by law. Information will be used in aggregate with no identifiable personal information used. Ortho Dermatologics’s not responsible for incorrect or inaccurate entry information whether caused by Internet users or by the equipment or programming associated with or utilized in the rebate or by any technical or human error which may occur in the processing of the entries. Sponsor is not responsible for computer system, phone line, hardware, software, or program malfunctions or other errors, failures or delays in computer transmissions or network connections that are human or technical in nature. Ortho Dermatologics’s failure to enforce any term of these terms shall not constitute a waiver of that provision

TERMS AND CONDITIONS
Limit to two rebate submissions per patient per calendar year. This offer cannot be combined with any other ORTHO DERMATOLOGICS™ EVOLENCE® promotional offers. The offer is only open to the name that appears on the itemized receipt. Offer valid only on EVOLENCE® treatments performed between January 1, 2009 through December 31, 2009. Receive a $50 rebate for each I mL syringe used for your EVOLENCE® treatment (up to three 1mL syringes). Offer valid only on EVOLENCE®. Rebate eligible on purchase of 1 mL syringe only. The EVOLENCE® syringes used in treatment must be purchased legally in the U.S. Submissions must be postmarked within 60 days of treatment. This offer cannot be combined with any other offer or promotion. Patients must be 18 years or older to qualify. By submitting this request to EVOLENCE®, you agree to all rules and conditions of this offer. ORTHO DERMATOLOGICS™ reserves the right to cancel or modify this offer without notice. This offer is available only to patients, excluding claims from ORTHO DERMATOLOGICS™ employees and their families, or employees of its dealers and distributors. This offer is non-transferable. Fraudulent submissions could result in prosecution. Offer void where prohibited by law, taxed, or otherwise restricted. Patient is responsible for any sales tax. Tax charged on pre-rebate price where required. Offer good only in the United States of America. EVOLENCE® rebates will be issued by check in U.S. dollars only. Allow 6 to 8 weeks for delivery. All requests become the property of ORTHO DERMATOLOGICS™ and will not be returned. ORTHO DERMATOLOGICS™ assumes no responsibility for lost, late, damaged, misdirected, misaddressed, incomplete or postage-due requests that fail to be properly delivered to the address stated for any reason. Such requests will not be honored. ORTHO DERMATOLOGICS™ its officers, directors and employees, parent, subsidiaries and related companies, are not responsible for any injury or loss whatsoever resulting from technical, hardware or software failures or malfunctions, and are not responsible for illegible, lost, late, or deleted submissions. Offer expires 12/31/09.

*I have read and understand the terms and conditions of this rebate.