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