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Consent
|
|
|
Risks Discussed & Consent Signed
|
|
|
FillerTreatment Record
|
|
|
Temples
• • •
|
Amount
|
|
Cheeks
• • •
|
Amount
|
|
Nasolabial Folds
• • •
|
Amount
|
|
Marionettes Lines
• • •
|
Amount
|
|
Upper Lip
• • •
|
Amount
|
|
Upper Lip Vermillion Border
• • •
|
Amount
|
|
Lower Lip
• • •
|
Amount
|
|
Lower Lip Vermillion Border
• • •
|
Amount
|
|
Jaw Line
• • •
|
Amount
|
|
Other Location
• • •
|
List other location
|
|
|
Amount
|
|
Filler diagram
|
|
|
Picture
|
Picture
|
|
Picture
|
Picture
|
|
Procedure Completion
|
|
|
Total Filler Amount (Syringe #1)
|
Select Filler (Syringe #1)
|
|
Total Filler Amount (Syringe #2)
|
Select Filler (Syringe #2)
|
|
Total Filler Amount (Syringe #3)
|
Select Filler (Syringe #3)
|
|
Tolerated well
|
|
|
Staff to Complete Procedure
|
|
