Pop-Up Tox Party
Space is limited - please complete a registration form to guarantee availability for injections.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Have you had Botox or any other neurotoxin (Dysport, Xeomin, Daxxify, Jeuveau) before?
*
Yes
No
Please list any known medication allergies
*
Any medical conditions you are currently being monitored or treated for?
*
Anything else you’d like us to know?
Submit
Should be Empty: