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

INJECTION - Exam and Procedure Medical Form

Dermatologist

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Published: March 22, 2016, 7:32 p.m.
Doctor: Dr. History Physical
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