Consents Signed
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Injection diagram
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Topical Numbing Applied:
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Pre-Treatment Photo
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Reason for visit
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Location 1:
• • •
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Location 2:
• • •
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Dermal Filler Type:
• • •
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Dermal Filler Type:
• • •
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Amount
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Amount
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Lot Number
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Lot Number
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Expiration Date
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Expiration Date
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Dermal Filler Type:
• • •
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Dermal Filler Type:
• • •
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Amount
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Amount
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Lot Number
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Lot Number
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Expiration Date
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Expiration Date
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Post Treatment Instructions:
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Post- Treatment Photo
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Post Treatment Assessment
• • •
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Patient Tolerated Well
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