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Consent
|
|
|
Risks Discussed & Consent Signed
|
|
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Botox/ Dysport Treatment Record
|
|
|
Botox or Dysport
• • •
|
|
|
Frontalis
|
|
|
Glabella
|
|
|
Left Crows Feet
|
|
|
Right Crows Feet
|
|
|
Brow Lift (under brows)
|
|
|
Bunny Lines
|
|
|
Gummy Smile (Pyriform Aperture)
|
|
|
Lip Flip (1mm above upper vermillion border)
|
|
|
Mentalis
|
|
|
Massester (bilateral total)
|
|
|
Platysmal Bands
|
|
|
Other
|
Location
|
|
Facial diagram
|
|
|
Picture
|
Picture
|
|
Picture
|
Picture
|
|
Picture
|
Picture
|
|
Picture
|
Picture
|
|
Procedure Completion
|
|
|
Total Botox
|
|
|
Total Dysport
|
|
|
Tolerated well
|
|
|
Staff to Complete Procedure
|
|
|
Custom Treatment Plan Recommendations
|
|
|
Follow Up
|
Follow Up Appointment Reminder
|
|
Care Instructions (electronic & paper)
|
|
