Brilliant Distinctions Sign Up (Step 1)


Hello, and thanks for your interest in the Brilliant Distinctions program offered by Allergan – the makers of Botox.


Please fill out the following form to get started in the Brilliant Distinctions program.  After completing the form, you’ll be taken to the Brilliant Distinctions website to continue your signup. Please ensure you select Dr. Adelglass as your doctor when prompted (at the Botox site).


Please note that ALL fields are required and your signup indicates your desire to hear about future products and/or services offered by Skintastic.


First Name:

Last Name:

EMail:

Phone: