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Cheekbone and Midface
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Using recommended product (Lyft or Voluma)
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Treating with other product (a.k.a outside recommendations)
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Reason
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Product used
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Number of Syringes used in Cheekbone and Midface
|
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Fine Lines, Oral Commissure, Marionettes
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Treating with recommended product (Juvederm Ultra Plus)
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Treating with other product (a.k.a outside parameters)
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Reason
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Product used
|
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Number of Syringes used in Fine Lines, Oral Commissure, and Marionette Lines
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Filler Hydrated with Sterile Saline - amount of saline per syringe
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Lips and Perioral Lines
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Used recommended product (Juvederm Ultra Plus or Vobella)
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Treating with other product (a.k.a outside parameters)
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Reason
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Product used
|
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Number of Syringes Used in Lip and Peri-Oral Lines
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Filler Hydrated with Sterile Saline
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Tear Trough
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Treating with recommended product (Restylane-L)
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Treating with other product (a.k.a outside parameters)
|
|
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Reason
|
Product used
|
|
Number of Syringes used in Tear Trough
|
|
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Chin, Jowls and Mental Crease
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Used recommended product (Juvederm Ultra Plus, Voluma or Lyft)
|
|
Treating with other product (a.k.a outside parameters)
|
|
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Reason
|
Product used
|
|
Number of Syringes used in Chin, Jowls, and Mental Crease
|
|
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Temples
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Treating with Recommended Product (Lyft or Voluma)
|
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Treated with other product (a.k.a. outside parameters)
|
|
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Reason
|
Product Used
|
|
Number of Syringes Used in Temples
|
|
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Treat Outside These Areas
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|
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Area treated
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Type of Filler used
|
|
Number of Syringes used
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Hydrated with Sterile Saline
|
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Sterile technique used
• • •
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Pain control achieved with
• • •
|
|
Take a picture of the areas to be treated – and draw in the location of your injection pattern
|
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Take a picture of the areas to be treated – and draw in the location of your injection pattern
|
|
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Take a picture of the areas to be treated – and draw in the location and amounts of your injections
|
|
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Did a Complication Occur?
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What Complication Occurred and How was it Managed?
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Additional Notes
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Follow up Recommendations
• • •
|
Follow-up for what date? (mm/yy)
/
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