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Botox or Dysport used?
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Skin was cleansed, and prepped with alcohol swab.
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Glabella
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Treating Glabella with Recommended dose (12-24 units)
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Treating Glabella Outside Recommended Dose
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Reason
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Number of units
|
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Frontalis
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Treating Frontalis with recommended dose (6-16 units)
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Treating frontalis Outside recommended dose
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Reason
|
Number of units
|
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Orbicularis Occuli
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Treating Orbicularis Occuli with recommended dose (12-24 units - 6-12 per side)
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Treating orbicularis occuli Outside recommended dose
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Reason
|
Number of units
|
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Eyebrow Lift
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Eyebrow lift preformed with recommended dose (2-4 units - 1-2 per side)
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eyebrow lift preformed Outside recommended dose
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Reason
|
Number of units
|
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Nasalis
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Treating Naslis inside recommended parameters (4-8 units total, 2-4 per side)
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Treating nasalis Outside recommended dose
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Reason
|
Number of units
|
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Orbicularis Oris
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|
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Treating Orbicularis Oris with recommended dose (2-4 units)
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Treat Orbicularis Oris Outside recommended dose
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Reason
|
Number of units
|
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DAO
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|
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Treating DAO inside recommended dose (4-6 total units, 2-3 on each side)
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Treating DAO outside recommended dose
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Reason
|
Number of units
|
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Masseter
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|
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Treating Masseter inside recommended dose (32-48 units total, 16-24 per side)
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Treating masseters Outside recommended dose
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Reason
|
Number of units
|
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Platysma
|
|
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Treating platysma inside recommended dose (12-24 units)
|
|
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Treating Platysma Outside recommended dose
|
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Reason
|
Number of units
|
|
Axilla
|
|
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Treating Axilla with recommended dose(40-100 units total, 20-50 per side)
|
|
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Treat Axilla Outside recommended dose
|
|
|
Reason
|
Number of units
|
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Treating Other area
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Area
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Reason
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Dose
|
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Take a picture of the areas to be treated – and draw in the location and amounts of your injections
|
|
|
Take a picture of the areas to be treated – and draw in the location and amounts of your injections
|
|
|
Total number of units used
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Additional Notes
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Did a Complication Occur?
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What Complication Occurred and How was it Managed?
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Follow up Recommendations
• • •
|
Follow-up for what date? (mm/yy)
/
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