Mind the Gap

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* 1. Are you interested in taking part in the Mind the Gap project?

Yes

No

Maybe

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* 2. Address

Name

Company

City/Town

Country

Email Address

Phone Number

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* 3. Secretary Name

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* 4. Secretary Number

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* 5. Profession

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* 6. Are you happy to be contacted by us in relation to this project?

Yes

No

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* 7. Do you treat the following in your practice

Hemifacial spasm

Dystonia

Spasticity

Migraine

Other (please specify)

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* 8. If you know, please tell us how many patients you treat on average:

Per week

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* 9. If you know, how many patients are treated in your unit/service

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* 10. Please estimate the average interval (in weeks) between injection cycles for your patients.