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RN/NP/PA
|
Consents Signed
|
|
Past Medical History
• • •
|
Past Medical History - Other
|
|
Previous Complications?
|
Complications Experienced
• • •
|
|
FILLERS
|
Injection Diagram
|
|
Juvederm
• • •
|
Restylane Location
• • •
|
|
Juvederm Product Used
|
Restylane Product Used
|
|
Amount
|
Amount
|
|
Lot Number
|
Lot Number
|
|
Expiration Date
|
Expiration Date
|
|
Juvederm
• • •
|
Restylane Location
• • •
|
|
Juvederm Product Used
|
Restylane Product Used
|
|
Amount
|
Amount
|
|
Lot Number
|
Lot Number
|
|
Expiration Date
|
Expiration Date
|
|
Juvederm
• • •
|
Restylane Location
• • •
|
|
Juvederm Product Used
|
Restylane Product Used
|
|
Amount
|
Amount
|
|
Lot Number
|
Lot Number
|
|
Expiration Date
|
Expiration Date
|
|
BOTOX + DYSPORT
|
Botox/Dysport Diagram
|
|
Reconstitution Date
|
|
|
Lot Number
|
Expiration Date
|
|
Crows feet
|
Units
|
|
Forehead
|
Units
|
|
Glabella
|
Units
|
|
Underarms
|
Units
|
|
Lip Flip
|
Units
|
|
Bunny Lines
|
Units
|
|
Massater
|
Units
|
|
DAOs
|
Units
|
|
Chin
|
Units
|
|
Platysmal Bands
|
Units
|
|
|
|
|
Other
|
Units
|
|
Photo's Were Taken?
|
Topical Arnica Applied?
|
|
Product Expected to Last
|
Bruising Noted?
|
|
When to Touch Up
|
Botox/Filler Post Procedure Care
|
|
Client consents to all information is valid and true
|
Notes
|
|
Signature of Medical Director
|
|
