|
Submental area or Jowls
|
Treating with recommended dose (4-12cc)
|
|
Treating outside recommended dose
|
|
|
Reason
|
# of cc:s used
|
|
Braline Fat – Front
|
Treating with recommended dose (4-12cc per side – 8-24 total)
|
|
Treating outside recommended dose
|
|
|
Reason
|
# of cc:s used
|
|
Flanks
|
Treating with recommended dose (4-12cc per side – 8-24 total)
|
|
Treating outside recommended dose
|
|
|
Reason
|
# of cc:s used
|
|
Abdomen
|
Treating with recommended dose (10-24 total)
|
|
Treating outside recommended dose
|
|
|
Reason
|
# of cc:s used
|
|
Lateral hip
|
Treating with recommended dose (4-12cc per side – 8-24 total)
|
|
Treating outside recommended dose
|
|
|
Reason
|
# of cc:s used
|
|
Banana Roll
|
Treating with recommended dose (4-12cc per side – 8-24 total)
|
|
Treating outside recommended dose
|
|
|
Reason
|
# of cc:s used
|
|
Knees
|
Treating with recommended dose (4-10cc per side – 8-20 total)
|
|
Treating outside parameters
|
|
|
Reason
|
# of cc:s used
|
|
Treating Outside These Areas
|
|
|
Area treated
|
Number of cc:s used
|
|
Sterile technique used
• • •
|
Pain control achieved with
• • •
|
|
Treated with the recommended dosage of .2cc of 1% Deoxycholic Acid in each square centimeter within the outlined area
|
|
|
Take a picture of the areas to be treated – and draw in the location of your injection pattern
|
|
|
Take a picture of the areas to be treated – and draw in the location and amounts of your injections
|
|
|
Lot number
|
Expiration date
|
|
Did a Complication Occur?
|
What Complication Occurred and How was it Managed?
|
|
Additional Notes
|
|
|
Follow up Recommendations
• • •
|
Follow-up for what date? (mm/yy)
/
|
