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Your Name (required) first name and surname

Your Email (required)

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Do you have BEB (required)

How long have you had BEB (required)

Treating Doctor

Current Treatment
BotoxDysportXeominOther

If "Other", what sort of treatment are you having?

Location - Country (required)

Location - State (required)

Address

It would be very useful if you would add your phone number as there are sometimes occasions where it would be helpful to have quick contact for administrative purposes. It would never be shared with other members.

Home Phone

Mobile

Contact (required) - Would you like to be notified of fellow members in your State? This will enable you to contact them and for them to contact you. Only your name and email address will be forwarded.
YesNo

Further Information you may like to tell us

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Last updated: 11 October, 2016