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Before Photo
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After Photo
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Botox Face Diagram
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Type of needle used
|
|
Botox
|
Risks of Neurotoxin Statement
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Lot # / Expiration Date
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Additional notes
|
|
Botox Consent
|
Consent Form Signed
|
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Injection site
• • •
|
Other injection site:
|
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Total number of units
|
Botox / Xeomin
|
|
Glabella
|
Units
|
|
Forehead
|
Units
|
|
Crows feet
|
Units
|
|
Bunny Lines
|
Units
|
|
Other
|
Units
|
|
|
Post Procedure Bruising
|
|
Filler
|
Filler Consent
|
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Does patient have history of HSV?
|
Filler Type
• • •
|
|
___ cc's
|
|
|
Injection site
• • •
|
Other injection site:
|
|
Lot # / Expiration Date
|
Additional notes
|
|
Ice given?
|
Anesthetic used
|
|
Post Procedure Bruising or Swelling?
|
|
