kybella Treatment Sheet
First Name
Last Name
Email
Patient email on file
DATE OF BIRTH
/
Month
/
Day
Year
Date
Consultation Checklist
Evaulate patient's submental fulness
Review and discuss the KYBELLA® treatment option. Use patient materials as appropriate
Capture patient photos in frontal, lateral, and oblique views
TREATMENT NOTES
Indicate area treated and complete the treatment notes.
Pencil in treatment (1)
Treatment Date
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Month
-
Day
Year
Date
Vial Lot Number(s)
Total Dose Administered (mL)
Notes
Pencil in treatment (2)
Treatment Date
-
Month
-
Day
Year
Date
Vial Lot Number(s)
Total Dose Administered (mL)
Notes
Pencil in treatment (2)
Treatment Date
-
Month
-
Day
Year
Date
Vial Lot Number(s)
Total Dose Administered (mL)
Notes
Provider Name
Provider Signature
Clear
Date
-
Month
-
Day
Year
Date
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