|
CONSULT
|
|
|
CONSULTATION
|
|
|
Glabella/Units
|
Frontalis/Units
|
|
Crows feet/Units (RIGHT)
|
Crows feet/Units (LEFT)
|
|
Nasalis/Units
|
Mentalis/Units
|
|
DAO/Units
|
Orb.Oris/Units
|
|
Masseter/Units
|
Other/Notes
|
|
Total Units Recommended
|
|
|
Consult Provider
|
|
|
TREATMENT
|
|
|
TREATMENT
|
|
|
Allergies
|
|
|
Good Faith Performed?
|
Med Hx Reviewed?
|
|
Consent
|
Before Photos Taken?
|
|
ETOH Prep?
|
Pre/Post Ice
|
|
LOT#
|
Exp. Date
|
|
Glabella/Units
|
Frontalis/Units
|
|
Crows feet/Units (RIGHT)
|
Crows feet/Units (LEFT)
|
|
Nasalis/Units
|
Mentalis/Units
|
|
DAO/Units
|
Orb.Oris/Units
|
|
Masseter/Units
|
Other/Notes
|
|
Total Units Given
|
|
|
Tolerated Tx Well?
|
No Adverse Reactions Noted Upon D/C?
|
|
Verbal/Written Post Instructions Given?
|
Pt Verbalized Understanding of all Post Instructions?
|
|
Follow Up
|
|
|
Treatment Provider
|
|
