Please complete the following form if you plan to receive or have already received Botox injections from the Division of Thoracic Surgery’s Thoracic Outlet Syndrome program at Massachusetts General Hospital.

If you select “Before Botox” from the dropdown menu, you will be prompted to list the symptoms you are currently experiencing and rate their severity. Fill out the "Before Botox" form one day before receiving treatment.

If you select “After Botox” from the dropdown menu, you are patient who has already received Botox injections from Mass General. You will be prompted to list the symptoms you experienced prior to your treatment and rate their percent improvement since treatment. Fill out the "After Botox" form 4-5 weeks post-treatment.

Important note: Some questions on this form may appear or disappear based on your responses. We recommend that you save a copy of your completed form for future reference.

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Requestor Information

If you are an international patient, please complete the International Patient Appointment Form.

Patient Information


About Our Treatment
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