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Botox Consent
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Filler Consent
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Reason for visit
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Reason for visit detail
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Areas of Concern
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Areas of concern detail
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Other concerns
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Previous treatments?
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Specify previous tx
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Previous treatment detail
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Complications?
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Complications experienced
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Additional history notes
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Contraindications to Treatment?
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Specifiy contraindications
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Examination
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Wrinkle Location
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Forehead
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Glabella
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Crow's Feet
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Infraorbital
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Bunny Lines
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Lip Lines
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Chin
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Frown
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Other
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Platsymal Bands?
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Number of platysmal bands
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Brow
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Brow position
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Brow ptosis
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Severity
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Midface
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Cheeks/Malar
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Cheeks/Zygoma
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Tear troughs
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Lateral Orbital Hollows
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Nose
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Perioral
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Nasolabial Folds
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Lip lines
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Lip Volume
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Oral Commisures
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Melomental Folds
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Jowls
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Additional Exam Notes
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Photo 1
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Photo 2
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Photo 3
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Photo 4
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Photo 5
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Photo 6
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Assessment
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Assessment Choices
• • •
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Assessment Detail
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Filler Region
• • •
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Est # of syringes
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Plan
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Neurotoxin
• • •
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Topical Anesthetic
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Filler Choices
• • •
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Plan Details
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Procedure Note - Botox/Xeomin/Dysport
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Neurotoxin #1
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Lot Number / Expiration Date
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Neurotoxin #2
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Lot Number / Expiration Date
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Skin Cleanser
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Botox/Xeomin / Dysport Units
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Forehead
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Glabella
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Crows Feet
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Nasalis
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Lat. Eyebrow Depressors
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Infraorbital
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Perioral
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DAO
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Mentalis
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Anterior Neck
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Headache
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Hyperhidrosis
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Total Units Injected
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Botox/Dysport Notes
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Procedure Note - Dermal Filler
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Filler #1
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Number of syringes
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Lot / Expiration Date
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Filler #2
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Number of syringes
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Lot / Expiration Date
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Filler #3
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Number of syringes
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Lot / Expiration Date
/
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Anesthesia?
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Anesthetic Details
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Anesthetic Used
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Tear Troughs
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Nasal Ridge
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"11s" / Glabella
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Nasolabial Folds
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Brow Lift
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Lips
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Cheeks
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Chin
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Columnella
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Perioral Wrinkles
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Marionette Lines
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Temples
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Scars
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Other
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Dermal Filler Notes
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Complications
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Complications details
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Follow-Up
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Botox/Filler Diagram
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