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ASSESSMENT
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Location of Wrinkles
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Forehead (Frontalis)
• • •
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Glabellar (Corrugator Supercilii, Depressor Supercilii, Procerus)
• • •
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Lateral Canthas (Orbicularis Oculi)
• • •
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Smoker's Lines (Orbicularis Oris)
• • •
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Chin (Mentalis)
• • •
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Other
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Platsymal Bands?
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Number of platysmal bands
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BROW POSITION
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Brows
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Brow Position
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Severity of Asymmetry
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Brow Position Comments
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PRE TREATMENT PHOTOGRAPHY
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No expression
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Frontalis
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Glabellar
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Orbicularis Oris
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Orbicularis Oculi Left
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Orbiculars Oculi Right
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Other
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Other
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PLAN
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Botox/Filler Diagram
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Injection Photo
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Neurotoxin Treatment Area (s)
• • •
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Neurotoxin
• • •
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Lot Number:
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Expiration Date
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PROCEDURE NOTE
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Skin Cleanser
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Number of Units
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Forehead
/
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Glabella
/
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Crows Feet
/
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Nasalis
/
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Lat. Eyebrow Depressors
/
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Infraorbital
/
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Perioral
/
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DAO
/
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Mentalis
/
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Anterior Neck
/
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Hyperhidrosis
/
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Total Units Injected
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POST TREATMENT PHOTOGRAPHY
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Follow-up Photography
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No expression
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Frontalis
|
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Glabellar
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Orbicularis Oris
|
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Orbicularis Oculi Left
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Orbiculars Oculi Right
|
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Other
|
Other
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Notes
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POST PROCEDURE
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Complications
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Complication(s) Notes
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EDUCATION
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Home Care Instructions
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Follow-Up
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Treatment Provider
• • •
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Supervising Clinician
• • •
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Medical Director Consulted
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Medical Director Consultation Notes
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