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Hylenex Contraindication Review
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Bee Sting Allergy
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Vaccines in past 2 weeks or next 2 weeks?
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Using furosemide, benzodiazepines, phenytoin, dopamine, and α-adrenergic agonists?
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Any active infection or on ABX?
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Recent or upcoming dental appointments (2 weeks)?
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Hx of Autoimmune Disease?
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Does patient have history of HSV?
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Filler History
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Date of last filler treatment
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Type of filler to be dissolved
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Hylenex Treatment
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Signs of vascular occlusion?
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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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Ice given?
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Arnica provided?
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Post Procedure Bruising or Swelling?
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Allergic reaction symptoms present post injection
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Injection Performed By
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Before Photo
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Before Photo
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