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PRECEPTORSHIP
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Request a Mentor

If you are an existing INA Member, please click here to register.

To participate in a preceptorship, INA membership is mandatory. Upon completion of this form your membership application will be submitted. There is no cost for membership.

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Pre-Activity Survey

What is your specialty?(Required)

Please specify your specialty(Required)

Type of Practice(Required)

Please specify your type of practice(Required)

Number of years in practice(Required)

Are you currently injecting botulinum neurotoxin?(Required)

Yes

No

If yes, how long have you been injecting botulinum neurotoxin?(Required)

If yes, what clinical conditions do you currently treat with botulinum neurotoxin? (Select all that apply)(Required)

Adult spasticity (upper and lower limb)

Pediatric spasticity (upper and lower limb)

Cervical dystonia

Focal limb dystonia

Tremor

Oromandibular dystonia

Spasmodic dysphonia

Meige syndrome

Blepharospasm

Sialorrhea

Hemifacial Spasm

Tics

Hyperhidrosis

Migraine/Other types of headaches

Urologic disorders

Aesthetic/Cosmetic

Pain

Other

Please specify other clinical condition(Required)

Number of patients you inject weekly(Required)

Do you use localization/guidance?(Required)

Yes

No

What type of localization/guidance do you utilize?(Required)

(Select all that apply)

EMG

E-Stim

Ultrasound

Other

N/A

Please specify other localization/guidance(Required)

Please identify what clinical conditions you would like to focus on at this preceptorship (Select all that apply)(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

Other

Please specify the other clinical condition(s) you would like to learn(Required)

Request an Injector Preceptorship

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

First Choice(Required)

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Tuesday and Thursday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Monday, Tuesday, Thursday, and Friday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Tuesday and Thursday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Monday and Wednesday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Monday, Tuesday, Wednesday, and Friday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Wednesdays
A shadowing application needs to be completed (the facility will send this to you)
Immunization verification
Drug screening: The drug screening will need to be done in advance of the preceptorship. You will need to do the drug screening in your home city/state. The facility will submit the order for the test and you will have a couple of days to visit an approved facility near your home to complete the test.

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Monday, Tuesday, Wednesday, Thursday, and Friday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days to injection training
Preceptorships can be scheduled on Monday, Tuesday, Wednesday, and Thursday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Tuesday, Wednesday, and Thursday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Tuesday, Wednesday, and Thursday
Check in at security with ID

Please note the following restrictions:

Preceptorship must be booked a minimum of 30 days prior to the injection training session
Preceptorships can be scheduled on Monday, Wednesday, and Thursday
Check in at security with ID

Date First Choice(Required)

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Date Second Choice(Required)

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Alternate Choice (optional)

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Documentation

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