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Before Photo
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Botox
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Botox Consent
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___ units
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Botox / Dysport
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Injection site
• • •
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Other injection site:
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Lot # / Expiration Date
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Additional notes
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Botox Face Diagram
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Filler
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Filler Consent
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Does patient have history of HSV?
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Filler Type
• • •
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___ cc's
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Injection site
• • •
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Other injection site:
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Lot # / Expiration Date
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Additional notes
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Face Diagram
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Type of needle used
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Ice given?
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Anesthetic used
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