Pre-Treatment
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Are Consents Signed?
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Injection diagram - Facial Musculature
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Injection diagram - Traditional Outline
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Patient Treatment Modification Consent
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Surgical Hx
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Previous Complications?
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Complications Experienced
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Before and After Images
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Clinical Picture Before 1
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Clinical Picture Before 2
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Clinical Picture Before 3
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Clinical Picture Before 4
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Clinical Picture After 1
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Clinical Picture After 2
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Clinical Picture After 3
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Clinical Picture After 4
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Dermal Filler
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Dermal Filler
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Area Injected
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amount
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Amount
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Lot Number
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Lot Number
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Expiration Date
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Expiration Date
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Lot Number
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Lot Number
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Expiration Date
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Expiration Date
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Neurotoxin
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Neurotoxin
• • •
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Area Injected
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Amount
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Lot Number
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Lot Number
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Expiration Date
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Expiration Date
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Post Treatment
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Bruising Noted?
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Take home Ice Given?
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Topical Arnica Applied?
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Botox/Filler Post Procedure Care
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RN Completing Note
• • •
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