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Consents Signed
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Last Kybella Treatment?
|
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Past Medical History
• • •
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Past Medical History- Other
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Previous Complications?
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Complications Experienced
|
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Pregnant?
|
Breastfeeding?
|
|
Risks/Benefits Reviewed and questions answered
|
|
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Amount
|
# Injection Points
|
|
Expiration Date
|
Lot
|
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Injection Diagram
|
Before Photo
|
|
Before Photo
|
Before Photo
|
|
Before Photo
|
|
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Submental
|
|
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Jowls
|
|
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Jawline
|
|
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Abdomen
|
|
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Bra Bulge
|
|
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Upper Back Thigh
|
|
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Other
|
|
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Performed By:
|
|
|
Conversation Notes
|
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