Crow's Feet Study Survey

Therapeutics Clinical Research is conducting a clinical research study evaluating a medication and its potential to temporarily reverse the effects of Botulinum Toxin for crow's feet wrinkles. In order to determine if you pre-qualify for this study, we will ask you a few questions about your condition. You may stop answering at any time and you do not need to answer any questions that make you feel uncomfortable.

All information you provide will be kept strictly confidential and will not be shared without your permission, except as required by law. Please feel free to call us for more information at (858) 571-6800.

By providing your contact information, you agree to receive phone calls, emails and/or texts from Therapeutics Clinical Research.

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* 1. Tell us about yourself:

Name:

Email Address:

Phone Number:

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* 2. Are you 18 years of age or older?

Yes

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* 3. If female, are you pregnant, nursing, or planning to be pregnant?

Yes

N/A; I am male

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* 4. Do you currently have crow's feet?

Yes

Not Sure

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* 5. Have you received any facial/cosmetic injections (e.g. Botox, fillers, etc.) in the past 3 months for your crow’s feet?

Yes

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* 6. Are you otherwise in good general health with no major medical conditions?

Yes

No (please list medical conditions):

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* 7. How did you hear about us?

Craigslist

Facebook

Google Ads

Instagram

Other website

Newsletter

Print advertisement

Radio

Word of mouth

Thank you for completing the survey. We will review your information and contact you shortly. If you would like additional information or would like to speak to a staff member directly, please feel free to call us at (858) 571-6800.

9025 Balboa Avenue Suite 105

San Diego, CA 92123