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Historical Cosmetic Complications
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History of Complications?
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Complications experienced
• • •
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Additional notes regarding complications
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Photo Consent
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Botox / Dysport
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Risks of Neurotoxin Statement
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Date of last Botox Treatment
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Hx of Neuromuscular Disorders
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Pregnant or Breastfeeding?
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Allergy to cows milk?
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Risks/Benefits Reviewed and questions answered
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Total # of units injected
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Lot #
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Expiration Date
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Lot #
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Expiration Date
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Neuromodulator Used
• • •
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Needle Length
• • •
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Frontalis
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Glabella
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Nasalis
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Depressor Septi Nasi
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Obicularis Oculi
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DAO
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Obicularis Oris
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Yonsei Point (Gummy Smile)
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Masseter
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Mentalis
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Platysma Bands
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Jawline Platysma
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Horizontal Neck Lines
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Trapezius
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Underarms
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Temporalis
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Additional notes
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Post care reviewed
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Post Procedure Bruising
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Alle / Aspire
• • •
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Injection Performed By
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Conversation Notes
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Injection Face Diagram
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Botox Before
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Botox Before
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Botox Before
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Botox Before
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Botox Before
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Botox Before
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Filler
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Hylenex
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Filler Contraindication Review
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Bee Sting Allergy
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Using furosemide, benzodiazepines, phenytoin, dopamine, and α-adrenergic agonists?
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Risks/Benefits Reviewed and questions answered
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Date of last filler treatment
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Does patient have history of HSV?
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Lidocaine allergy?
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Vaccines in past 2 weeks or next 2 weeks?
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Recent or upcoming dental appointments (2 weeks)?
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Any active infection or on ABX?
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Previous Facial Procedures/Injections
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Hx of Autoimmune Disease?
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Risks/Benefits Reviewed and questions answered
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Filler Treatment
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# of Syringes
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Filler Type
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Injection site
• • •
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Needle / Cannula
• • •
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# of Syringes
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Filler Type
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Injection site
• • •
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Needle / Cannula
• • •
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# of Syringes
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Filler Type
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Injection site
• • •
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Needle / Cannula
• • •
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# of Syringes
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Filler Type
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Injection site
• • •
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Needle / Cannula
• • •
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Anesthetic used
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Lot # / Expiration Date
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Lot # / Expiration Date
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Lot # / Expiration Date
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Lot # / Expiration Date
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Additional notes
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20u (.13ml) Patch test Completed
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Location patch test
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Reaction to patch test
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Hylenex Amount & Location
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Hylenex Lot # / Expiration
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Capillary Refill Intact?
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Ice given?
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Arnica provided?
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Post Procedure Bruising or Swelling?
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Post Filler Care
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Injection Performed By
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Allergic reaction symptoms present post injection
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Conversation Notes
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Before Photo
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Before Photo
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After Photo
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