Name:
Street:
City:
State:      Zip:   
Phone:
Email:

When was your first BOTOX® injection?
When was your last BOTOX® injection?
Where did you receive the injections?
When did you first notice problems?

Have you suffered from... Paralysis? Migraine Headaches? Difficulty Swallowing?
Other problems? (If other, please describe)

How long have the problems continued?
Do you still have the problems now?

Did you report the problems to a doctor? Yes No
(If yes, what was the doctor's diagnosis?)

Have you received medical treatment for the problems?

Did you receive BOTOX® for... Cosmetic Purposes? Headaches? Muscle Spasms?
Other condition? (If other, please explain)

Please tell us your story and describe your injuries in more detail:

Verify In order to minimize abuse/spam, please enter the text you see into the input field below. (Numbers only).
Verify Code
Enter code below as shown:
 

Home | News | Medical Conditions | Contact Us