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How much do you know about injectable treatments - August 2017
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1.
What is your Name and Surname?
(Required.)
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2.
Which Renewal Institute branch do you visit most often?
(Required.)
Bedfordview
Brooklyn
Cape Quarter
Claremont
Constantia
Durban
Fourways
Hillcrest
Illovo
Irene
Morningside
Parkhurst
Stellenbosch
Umhlanga
West Rand
Willowbridge
3.
If you would like us to update your e-mail address on our client database, please fill in your current e-mail address below?
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4.
Please select your gender?
(Required.)
Male
Female
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5.
Please select your age group:
(Required.)
18-25
26-35
36-45
46-55
56-65
Above 66
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6.
Have you had any botulinum toxin (Botox or Dysport), or dermal filler treatments done?
(Required.)
Yes
No
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7.
In which of the below areas have you had botulinum toxin done:
(Required.)
Between the eyes
Crow's feet (around the eyes)
Forehead
Eyebrow lift
Chin
Smoker's lines
Under Eyes
Jowls, or for jawline definition
Botulinum toxin for migraine treatment
Botulinum toxin for TMJ / Bruxism (teeth grinding)
I have not had botulinum toxin (Botox / Dysport) treatment.
Other (please specify)
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8.
If you had treatments with a botulinum toxin, did it work by reducing the appearance of wrinkles?
(Required.)
Yes
No
Not as well as I was expecting
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9.
If you have a botulinum toxin treatment, how long did the effects last?
(Required.)
1-2 months
3-4 months
Longer than 4 months
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10.
In which of the below areas have you had dermal filler treatment?
(Required.)
Nasolabial folds (lines from the end of the nose to the end of the lips)
Perioral area (wrinkles around the lips)
Cheek Wrinkles
Marionette lines (lines from the corners of the mouth to the jawline, accentuating the downturn of the mouth)
Lips, for added volume, or balancing
Under-eye dark circles
Hollow cheeks
Temples
Other (please specify)
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11.
If you had dermal filler treatments, did it work by improving the area of concern?
(Required.)
Yes
No
Not as well as I expected
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12.
If you had dermal filler treatment, how long did the effects last?
(Required.)
6months
9months
More than a year
Other (please specify)
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13.
At which age did you have your first botulinum toxin or dermal filler treatment?
(Required.)
Between ages 20 - 30
Between ages 31 - 40
Between ages 41 - 50
Between ages 51 - 60
61+
I have never had this treatment done before
14.
What is botulinum toxin made of:
Purified protein
Poison
I don't know
15.
What elements should you consider to ensure your injectable treatments are safe:
Check that you are being injected with a genuine product
The treatment is administered by a qualified & experienced Aesthetic Doctor
The treatment is administered in a Doctor's practice, in a sterile environment
The Doctor makes use of correct waste disposal procedures
The Doctor insists on a two week follow-up appointment
All of the above
16.
When receiving filler, which are the areas one must take caution with, and ensure one has an experienced injector:
Between the eyes (ll lines)
Nasolabial folds
Anywhere near the nose
The middle of the forehead
Temple area
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17.
Would you like a Renewal Institute staff member to contact you to discuss the survey?
(Required.)
Yes
No
