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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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Brow Position
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Severity of Asymmetry/Hooding
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Brow Position Comments
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PRE-TREATMENT PHOTOGRAPHY
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No expression
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Smile
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Frontalis
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Glabellar
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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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PDO Thread Diagram
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Client PDO Thread Placement Photo
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PDO Thread Treatment Area (s)
• • •
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PDO Smooth/Twist Thread Selection
• • •
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PDO Lifting Thread Selection
• • •
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Lot # - Expiration Date
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PROCEDURE NOTE
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Procedure Note
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# of PDO Smooth Threads Used
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# of PDO Lifting Threads Used
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Frontalis (Forehead)
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Frontalis (Forehead)
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Temporalis
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Nasalis
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Zygomaticus (Cheeks)
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Zygomaticus (Cheeks)
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Corrugator/Procerus
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Corrugator/Procerus
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Depressor Anguli Oris (DAO) (Downturned Smile)
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Depressor Anguli Oris (DAO) (Downturned Smile): {{value}}
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Orbicularis Oculi (Crows Feet)
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Orbicularis Oculi (Brow Lift)
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Sternocleidomastoid (Vertical Neck Lines)
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Sternocleidomastoid (Vertical Neck Lines)
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Platysmal Bands (Vertical Neck Lines)
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Platysma (Jaw Line)
/
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Diagastric (Double Chin)
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Diagastric (Double Chin)
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Mentalis (Pebbled Chin)
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Orbicularis Oris (Perioral Lines)
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Nasalis
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Other
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Other
/
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Smooth Threads Notes
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Lifting Threads Notes
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Smooth Threads Notes
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Lifting Threads Notes
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POST-TREATMENT PHOTOGRAPHY
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Follow-up Photography
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No expression
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Smile
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Frontalis
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Glabellar
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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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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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