|
Historical Cosmetic Complications
|
|
|
History of Complications?
|
Complications experienced
• • •
|
|
Additional notes regarding complications
|
|
|
|
|
|
Contraindications for Treatment & Risk Review
|
|
|
Pregnant or Breastfeeding?
|
Hx of Neuromuscular Disorders
|
|
Allergy to cows milk?
|
Risks of Neurotoxin Statement
|
|
Injection Pattern Recommendations:
|
|
|
Date of last Botox Treatment
|
|
|
Total # of units injected
|
Total # Units refinement + previous treatment
|
|
Lot #
|
Expiration Date
|
|
Neuromodulator Used
• • •
|
Needle Length
• • •
|
|
|
|
|
Frontalis
|
Glabella
|
|
Nasalis
|
Obicularis Oculi
|
|
Obicularis Oris
|
Depressor Septi Nasi
|
|
Mentalis
|
DAO
|
|
Platysmal Bands
|
Jawline Platysma
|
|
Masseter
|
Trapezius
|
|
Underarms
|
Temporalis
|
|
Injection Performed By
|
Additional notes
|
|
Post care reviewed
|
Post Procedure Bruising
|
|
Conversation Notes
|
|
|
|
|
|
Injection Face Diagram
|
|
|
Botox Before
|
Botox Before
|
|
Botox Before
|
Botox Before
|
