|
RN/NP/PA
|
Consents Signed
|
|
Previous Complications
• • •
|
Past Medical History- Other
|
|
Previous Complications?
|
Complications Experienced
|
|
Amount
|
Injection Diagram
|
|
Amount of Syringes
|
Lot
|
|
Expiration Date
|
Patient Signature
|
|
Submental
|
|
|
Jowls
|
|
|
Jawline
|
|
|
Abdomen
|
|
|
Bra Bulge
|
|
|
Upper Back Thigh
|
|
|
Other
|
|
