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TOXINS 2026
PRECEPTORSHIP
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Mentor Response

Mentor Name(Required)

Job Number(Required)

Date(Required)

Time(Required)

Practice/Facility Location(Required)

Do you wish to provide an alternate location?

No

Yes

Please provide the alternate address(Required)

Does the learner need to complete paperwork to enter your practice/facility?(Required)

No

Yes

Please provide entry instructions(Required)

Please check off the conditions that you are injecting for this preceptorship(Required)

Adult spasticity (upper and lower limb)

Pediatric spasticity (upper and lower limb)

Cervical dystonia

Focal limb dystonia

Tremor

Sialorrhea

Oromandibular dystonia, Spasmodic dysphonia

Meige syndrome, Hemifacial Spasm, Blepharospasm

Hyperhidrosis

Migraine/Other types of headaches

Urologic disorders

Aesthetic/Cosmetic

Number of Adult spasticity patients(Required)

Please enter a number greater than or equal to 1.

Number of Pediatric spasticity patients(Required)

Please enter a number greater than or equal to 1.

Number of Cervical dystonia patients(Required)

Please enter a number greater than or equal to 1.

Number of Focal limb dystonia patients(Required)

Please enter a number greater than or equal to 1.

Number of Tremor patients(Required)

Please enter a number greater than or equal to 1.

Number of Sialorrhea patients(Required)

Please enter a number greater than or equal to 1.

Number of Oromandibular dystonia, Spasmodic dysphonia patients(Required)

Please enter a number greater than or equal to 1.

Number of Meige syndrome, Hemifacial Spasm, Blepharospasm patients(Required)

Please enter a number greater than or equal to 1.

Number of Hyperhidrosis patients(Required)

Please enter a number greater than or equal to 1.

Number of Migraine/Other types of headaches patients(Required)

Please enter a number greater than or equal to 1.

Number of Urologic disorders patients(Required)

Please enter a number greater than or equal to 1.

Number of Aesthetic/Cosmetic patients(Required)

Please enter a number greater than or equal to 1.

Do you require in-kind Botox?(Required)

No

Yes

Botox dosage(Required)

Do you require in-kind Xeomin?(Required)

No

Yes

Xeomin dosage(Required)

Member Login

Username(Required)

Password(Required)

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Preceptorship

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