|
Consent
|
|
|
Risks Discussed & Consent Signed
|
|
|
Filler Treatment Record
|
|
|
Numbing
• • •
|
|
|
Temples
|
Note
|
|
Tear Troughs
|
Note
|
|
Cheeks
|
Note
|
|
Nasolabial Folds
|
Note
|
|
Marionettes Lines
|
Note
|
|
Oral Commisure
|
Note
|
|
Lips
|
Note
|
|
Angle of Mandible
|
Note
|
|
Jaw Line
|
Note
|
|
Pre Jowl Sulcus
|
Note
|
|
Chin
|
Note
|
|
Other
|
Location & Note
|
|
Other
|
Location & Note
|
|
Filler diagram
|
Filler diagram
|
|
Before Picture
|
Before Picture
|
|
Before Picture
|
Before Picture
|
|
Before Picture
|
Before Picture
|
|
Before Picture
|
Before Picture
|
|
Before Picture
|
Before Picture
|
|
Procedure Completion
|
|
|
Total Filler Amount (Filler #1)
|
Select Filler (Filler #1)
|
|
Total Filler Amount (Filler #2)
|
Select Filler (Filler #2)
|
|
Total Filler Amount (Filler #3)
|
Select Filler (Filler #3)
|
|
Total Filler Amount (Filler #4)
|
Select Filler (Filler #4)
|
|
Tolerated well
|
|
|
After Picture
|
After Picture
|
|
After Picture
|
After Picture
|
|
After Picture
|
After Picture
|
|
After Picture
|
After Picture
|
|
After Picture
|
After Picture
|
|
Staff to Complete Procedure
|
|
|
Custom Treatment Plan Recommendations
|
|
|
Follow Up
|
Follow Up Appointment Reminder
|
|
Care Instructions (electronic & paper)
|
|
