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History
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Do you have
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Hypersensitivity to Botulinum A toxin products
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Previous treatments?
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Specify previous tx
• • •
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Previous treatment detail
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Infection at the proposed injection site(s)
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Bleeding Disorders
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Cardiac Disease
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Active Skin Disease
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Do you or a family member have
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Amyotropic Lateral Sclerosis
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Motor Neuropathy
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Myasthenia Gravis
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Lambert-Eaton Syndrome
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Facial Nerve Palsy
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Are you
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Pregnant
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Breast-feeding
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Medications
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Do you take or have recently been on any of the following medications
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Warfarin or Anti-Platelet Agents
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Quinidin
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Aminoglycosides
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Magnesium Sulfate
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Curare-like Nondepolarizing Blockers
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Anticholinesterases
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Lincosamides
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Succinylcholine Chloride
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Polymyxins
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Physical
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Glabellar lines smoothed out by physically spreading them apart
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Skin infection at site of injection
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Evidence of muscular atrophy
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Evidence of petechia or bruising
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Facial Asymmetry
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Ptosis
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Deep dermal scarring
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Thick sebaceous skin
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Dermatochalasis (excessive redundant skin)
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PHOTOGRAPHS
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Photograph
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Photograph
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Photograph
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Photograph
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Photograph
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Photograph
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Photograph
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Photograph
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Photograph
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Photograph
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Assessment
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Assessment Choices
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Assessment Detail
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Estimated # Units
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Filler Region
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Est # of syringes
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Plan
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Neurotoxin
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Topical Anesthetic
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Filler Choices
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Plan Details
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PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE
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RISKS AND COMPLICATIONS
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Risks of Neurotoxin Statement
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CONSENT TO BOTULINUM TOXIN “A” TREATMENT
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Consent Form Signed
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Procedure Note - Botox/Xeomin/Dysport
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Neurotoxin #1
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Lot Number / Expiration Date
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Neurotoxin #2
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Lot Number / Expiration Date
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Skin Cleanser
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Dilution Amount
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Botox/Xeomin / Dysport Units
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Forehead
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Forehead
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Glabella
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Glabella
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Crows feet
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Lateral Canthal Lines
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Nasalis
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Lat. Eyebrow Depressors
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Perioral
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Infraorbital
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DAO
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Mentalis
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Anterior Neck/ Platysmal bands
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Headache
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Hyperhidrosis
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Other (additional area)
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Total Units Injected
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Botox/Dysport Notes
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Filler #1
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Number of syringes
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Lot / Expiration Date
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Filler #2
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Number of syringes
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Lot / Expiration Date
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Filler #3
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Number of syringes
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Lot / Expiration Date
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Dermal Filler Notes
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Anesthesia?
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Anesthetic Details
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Anesthetic Used
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Complications
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Post procedure bruising
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Complications details
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Botox/Filler Diagram
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TREATMENT Education
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RESULTS
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Follow-Up
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PAYMENT
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Additional Notes
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NP/PA
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Date
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