Thank you for your interest in XEOMIN (incobotulinumtoxinA). To place your order, please complete the order form below. To ensure your order is placed in a timely manner, please fill in all required fields. If you encounter any issues while completing your order form, contact My Merz Solutions: MyMerzSolutions@merz.com 1-844-4MY-MERZ, Option #11 *Required fieldAccount Number*First Name*Last Name*Practice Name*Address*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCity*ZIP*Email Address* Phone*SpecialtyPO NumberXEOMIN (incobotulinumtoxinA) 50-U VialsXEOMIN (incobotulinumtoxinA) 100-U VialsVial TotalTotal requested must be 5 or greater. If you enter a quantity outside of the guidelines of this limited-time offer, the processing of your order may be delayed. Please see the email you received for maximum order quantity. Product purchased as part of this limited-time offer is not eligible for return. You can purchase any combination of XEOMIN 50U and 100U vials as long as the buy-in quantity is met. Only direct purchases qualify for this offer.If you are also a Merz Neurosciences customer you will receive a separate email communication with order details from Merz Neurosciences.SubmitINDICATIONS AND USAGE XEOMIN (incobotulinumtoxinA) for injection, for intramuscular use is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines with corrugator and/or procerus muscle activity in adult patients. IMPORTANT SAFETY INFORMATION WARNING: DISTANT SPREAD OF TOXIN EFFECT See full prescribing information for complete BOXED WARNING. The effects of XEOMIN and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults, particularly in those patients who have underlying conditions that would predispose them to these symptoms. CONTRAINDICATIONS Hypersensitivity reactions have been reported with botulinum toxin products (anaphylaxis, serum sickness, urticaria, soft tissue edema, and dyspnea). If serious and/or immediate hypersensitivity reactions occur further injection of XEOMIN should be discontinued and appropriate medical therapy immediately instituted. XEOMIN is contraindicated in patients with a known hypersensitivity to the active substance botulinum toxin type A, or to any of the excipients (human albumin, sucrose) in the formulation. Use in patients with an infection at the injection site could lead to severe local or disseminated infection. XEOMIN is contraindicated in the presence of infection at the proposed injection site(s). WARNINGS AND PRECAUTIONS The potency units of XEOMIN are specific to the preparation and assay method used and are not interchangeable with other preparations of botulinum toxin products. Therefore, Units of biological activity of XEOMIN cannot be compared to or converted into Units of any other botulinum toxin products. Treatment with XEOMIN and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. When distant effects occur, additional respiratory muscles may be involved. Patients may require immediate medical attention should they develop problems with swallowing, speech, or respiratory disorders. Dysphagia may persist for several months, which may require use of a feeding tube. Aspiration may result from severe dysphagia [See BOXED WARNING]. Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junctional disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored particularly closely when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including severe dysphagia and respiratory compromise from typical doses of XEOMIN. Glabellar Lines: Do not exceed the recommended dosage and frequency of administration of XEOMIN. In order to reduce the complication of ptosis the following steps should be taken: avoid injection near the levator palpebrae superioris, particularly in patients with larger brow depressor complexes; corrugator injections should be placed at least 1 cm above the bony supraorbital ridge. XEOMIN contains human serum albumin. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases and Creutzfeldt-Jakob disease (CJD). No cases of transmission of viral diseases or CJD have ever been reported for albumin. ADVERSE REACTIONS Glabellar Lines: The most commonly observed adverse reaction (incidence ≥ 2% of patients and greater than placebo) for XEOMIN was Headache (5.4%). DRUG INTERACTIONS Co-administration of XEOMIN and aminoglycoside antibiotics or other agents interfering with neuromuscular transmission, e.g., tubocurarine-type muscle relaxants, should only be performed with caution as these agents may potentiate the effect of the toxin. Use of anticholinergic drugs after administration of XEOMIN may potentiate systemic anticholinergic effects. The effect of administering different botulinum toxin products at the same time or within several months of each other is unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. USE IN PREGNANCY Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. XEOMIN should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. PEDIATRIC USE The safety and effectiveness of XEOMIN in patients less than 18 years of age have not been established. For more information, please see XEOMIN full Prescribing Information and Medication Guide.