Registration

Complete the registration by filling out the fields below.

I have read and agree to STI Technologies Terms and Conditions, as well as the Privacy Policy I hereby expressly consent to the collection, use, disclosure and retention of my personal information by STI as provided in the Privacy Policy *

Terms and Conditions *

Patient Information

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First Name *

Last Name *

Gender *

Date of Birth *

Month

Day

Year

Phone *

Email *

Address *

City *

Province *

Postal Code *

Card Information

Carrier

Group

Client ID *

Treating Physician Information

First Name *

Last Name *

Survey

Which healthcare practitioner do you work MOST regularly with to help manage your headaches overall? *

How did you first hear about BOTOX® as a treatment for your headaches? *

Do you have a public or private drug plan that help with the costs of medications *

How many different medications have you tried to help PREVENT the onset of headaches? These would be called prophylactic medications, which you would take on a regular basis. They are different from the medications you may take to stop a headache after it occurs, like Advil, Tylenol, Triptans, etc. *

Have you received BOTOX® injections in the past for headaches? *

Would you have considered BOTOX® injections for your headaches if you DID NOT have access to the BOTOX® Chronic Migraine Patient Support Program? *

How likely would you have tried BOTOX® injections for your headaches if you DID NOT have access to the BOTOX® Chronic Migraine Patient Support Program? *

I accept to receive electronic communications from STI Technologies Limited

Learn More

As part of the BOTOX^® Chronic Migraine Patient Support Program, we will send you useful information about your therapy, including but not limited to, reminders for your upcoming injection(s), the benefits of continuing therapy, plus any additional promotions that may become available throughout the life of the program.

You can expect approximately (4) emails within the next 12 months.