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ASSESSMENT
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Mid Face
• • •
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Lower Face
• • •
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Lips
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Lip Lines
• • •
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Other
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PRE PROCEDURE PHOTOS
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Photo 1
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Photo 2
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Photo 3
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Photo 4
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Photo 5
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Photo 6
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PLAN
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Dermal Filler #1
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Dermal Filler Treatment Area
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Number of syringes
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Lot Number
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Expiration Date
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Anesthetic Used
• • •
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Notes
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Dermal Filler #2
• • •
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Dermal Filler Treatment Area
• • •
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Number of syringes
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Lot Number
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Expiration Date
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Anesthetic Used
• • •
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Notes
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Dermal Filler #3
• • •
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Dermal Filler Treatment Area
• • •
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Number of syringes
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Lot Number
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Expiration Date
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Anesthetic Used
• • •
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Notes
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POST PROCEDURE PHOTOS
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Photo 1
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Photo 2
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Complications
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Complications Notes
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EDUCATION
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Home Care Instructions
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FOLLOW-UP
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Follow Up Comments
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TREATMENT PROVIDER
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SUPERVISING CLINICIAN
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Collaborated With Medical Director?
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Comments
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