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* 1. Have you had Botox injections before?

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* 2. If yes, what was the reason to get Botox?

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* 3. If you had Botox before, were you satisfied with the results?

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* 4. How long have you been looking for a Botox clinic?

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* 5. What are your most important criteria in choosing a cosmetic clinic?

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* 6. Are you planning to do the injection in the coming two weeks?

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* 7. How did you hear about us?

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* 8. Do you prefer Botox from Allergan of Dysport from Galderma

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* 9. Please fill in your contact information to receive the 10% discount coupon

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* 10. If you want us to contact you, what do you prefer?

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* 11. Please choose the date field to be two weeks from today

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