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Patient:
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Date of Birth:
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Chief Complaint:
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Notes:
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Past Medical History
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Past Medical History:
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Comments:
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Past Surgical History
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Comments:
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Meds:
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Allergies:
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Physical:
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Gen
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Comments:
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Resp
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Skin
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Psych
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Assessment/Plan
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Assessment:
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Plan:
• • •
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Neuromodulator (Botox Equivalent):
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Frontalis:
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DAO:
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Glabella:
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Mentalis:
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Orbicularis Oculi:
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Orbicularis Oris:
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Nasalis:
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Masseter:
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Auxilla:
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Filler:
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Midface:
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Area:
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Lower face:
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Area:
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Lips:
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Chest:
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Neck:
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Hands:
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Additional Comments:
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Images
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Images:
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Images:
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Images:
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Signature
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Administering Staff Signature:
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