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Reason for Visit
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Surgical Hx
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Previous Complications?
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Complications Experienced
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Past Medical History
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Past Medical History - Other
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Site 1 - Qty
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Site 1 - Units
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Site 1 - Location
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Site 2 - Qty
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Site 2 - Units
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Site 2 - Location
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Site 3 - Qty
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Site 3 - Units
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Site 3 - Location
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Site 4 - Qty
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Site 4 - Units
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Site 4 - Location
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Site 5 - Qty
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Site 5 - Units
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Site 5 - Location
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Site 6 - Qty
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Site 6 - Units
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Site 6 - Location
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Bruising Noted?
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Topical Arnica Applied?
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Take home Ice Given?
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Photo's Were Taken?
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Botox/Filler Post Procedure Care
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