Your name*

Your email*

Workplace*

Position*

Address*

Phone number*

Years of experience*
Please indicate how many years of experience you have working in the field of dystonia and/or spasticity. (To complete the program as a physician, you should already be treating patients with botulinum toxin or be prepared to start doing so when the program begins.)

Multidisciplinary team*
Are you working in a multidisciplinary team that includes both physicians and therapists? If you are applying together as a team, please let us know.

Motivation*
Please describe your motivation for applying to the program. (You can write as long text as you want in this field below, beyond the width.)

Please leave this field empty.