1. Generic Error
  2. [Hidden] Origin Name
  3. isPatient
  4. Section
  5. Panel1
  6. Panel 2
  7. Thank You Panel
  8. Submit
  9. MetaData

Something went wrong.
Please try again later.

To invite your patients to join the BOTOX® Savings Program, enter their mobile phone number or email address. Learn more

Patient

OR

Email is invalid

I have received consent from my patient to receive a one-time BOTOX® Savings Program text message from “AbbVie”, including program communications to the above mobile number. Message and data rates may apply. Patient is not required to consent as a condition of receiving goods or services. View Privacy Notice and Mobile Terms and Conditions.

By submitting this form, you are referring the above patient to the BOTOX® Savings Program and received the appropriate consent from the patient as noted above. Please share the following information with your patient. AbbVie may collect your personal data through your online and offline interactions with us, including your geolocation and internet activity. + Expand for more

We may also collect your online usage data automatically through cookies and similar technologies. We use this information for several purposes, such as to provide you with, administer, and improve our programs, services and products, customize your experiences, and for research and analytics. We retain your personal data for as long as necessary to fulfill these purposes or to comply with our record retention obligations. We do not sell your personal data, but may use and disclose your personal data with marketing and advertising partners to deliver you ads based on your interests inferred from your activity across other unaffiliated sites and services (“online targeted advertising”) and for website analytics. To opt out of the use or disclosure of your personal data for online targeted advertising or for website analytics, go to Your Privacy Choices on our website. For more information on the personal data categories we collect, the purposes for their collection, disclosures to third parties, and data retention, visit our Privacy Notice.

 

Through my submission of the BOTOX® Savings Program form, I received consent from my patient to the collection, use, and disclosure of their personal health data, as described in the Privacy Notice above and in AbbVie’s Privacy Notice in the “How We May Disclose Personal Data” section. My patient’s consent is required to process sensitive personal data under certain privacy laws, and the patient has the right to withdraw their consent by visiting “Your Privacy Choices” on AbbVie’s website. - Close for less

SUCCESS!

Your patient has been sent an invite to the BOTOX® Savings Program.

Please provide appropriate value in each field's default value property as per Analytics Tech Specs

Form Name:

Form Category:

Account Management, Contact, Interactions, Quiz, Registration, Services

 

Form Sub-Category:

Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story

Form MVA Name:

Form MVA Type:

Download, Form, Link, Share, Tool, Video

Form MVA Tier:

Form MVA Category:

Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other

 

Form PII Field Names for Masking:

Form Analytics Payload: