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Aesthetics
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Reason for visit
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Main area of concern
• • •
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Other areas of concern
• • •
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Comments
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Risks of Neurotoxin Statement
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Neurotoxin Consent Form
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Consent Form Signed
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Neurotoxin used
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Reconstitution
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Lot #
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Expiration
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Glabella Units
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Frontalis Units
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Obicularis Oculi Units
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Nasalis Units
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DAO Units
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Mentalis Units
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Platysma Units
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Other (additional area)
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Neurotoxin Diagram
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Post procedure bruising
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Dermal Filler
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Hyaluronic acid consent form
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Does patient have history of HSV?
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LIPS
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HA Type
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Type of needle used
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Comments
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Lot #
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Expiration
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NLF
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HA Type
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Type of needle used
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Comments
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Lot #
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Expiration
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MARIONETTE LINES
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HA Type
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Type of needle used
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Comments
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Lot #
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Expiration
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LIP LINES
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HA Type
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Type of needle used
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Comments
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Lot #
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Expiration
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TEAR TROUGHS
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HA Type
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Type of needle used
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Comments
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Lot #
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Expiration
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CHEEKS
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HA Type
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Type of needle used
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Comments
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Lot #
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Expiration
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Ice given?
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Disposition
• • •
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Post procedure education
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