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Botox/Filler
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Consents Signed
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Patient cleared for treatment
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Plasma Pen
• • •
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Has patient had this treatment done before?
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If yes, what brand and area?
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Were they happy with their results?
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Do they have any specific concerns/requests?
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Botox
• • •
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Amount
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Lot Number
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Expiration Date
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Injection diagram
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Injection Sites #2
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Injection Site #3
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Additional Information.
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If filler, which type?
• • •
|
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Area for Filler Placement
• • •
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Specify other area
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Amount
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Lot Number
|
|
Expiration Date
|
Injection diagram
|
|
Injection Sites #2
|
Injection Site #3
|
|
Additional Information.
|
|
