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Pre-Activity Survey

What is your specialty focus?(Required)

Please specify your specialty focus(Required)

Type of Practice(Required)

Please specify your type of practice(Required)

Number of years in practice(Required)

Number of patients you inject weekly(Required)

Number of patients you inject yearly(Required)

Please identify your learning goals for this conference

Self-Assessment

Please rank your current ability to:

	Excellent	Good	Fair	Poor
Evaluate clinical data, evidence-based recommendations, and practical experience in the use of botulinum neurotoxins for specific conditions, in order to properly assess and select appropriate patients for neurotoxin therapy
Demonstrate best practice procedures and techniques for neurotoxin injections, in order to improve clinical skills and optimize patient outcomes in the management of specific conditions
Apply optimal guidance and localization techniques, in order to improve efficacy in injecting BoNT for treatment of specific conditions

What is the most important thing you would like to learn at this conference?(Required)

Please allow a minimum of 7 business days to confirm your request.

Mentor First Choice(Required)

Date First Choice(Required)

Mentor Second Choice(Required)

Date Second Choice(Required)

Product Name(Required)

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