First Name
*
Last Name
*
Date
*
/
Month
/
Day
Year
Date
Email
*
Patient email on file
Recent NSAID or ASA
*
Yes
No
Date of Recent NSAID or ASA
-
Month
-
Day
Year
Date
Recent/Nursing
Yes
No
LMP
History of Cold Sores
Yes
No
Neurological Issues
Yes
No
Autoimmune Disease
Yes
No
Albumin (egg) Allergy
Yes
No
If YES to Above Questions Describe
Treatment History
Patient's first Dermal Filler Treatment
Yes
No
Date of last Dermal filler treatment
/
Month
/
Day
Year
Date
Previous Dermal filler Problems
If none put N/A
Informed consent given (Dermal Filler)
Yes
No
Lot Number (Dermal Filller)
If none put N/A
Exp. Date (Dermal Filler)
/
Month
/
Day
Year
Date
Patient's first BoNT Treatment
Yes
No
Date of last BoNT treatment
/
Month
/
Day
Year
Date
Previous BoNT Problems
Informed Consent Given (BoNT Treatment)
Yes
No
Lot Number (BoNT Treatment)
If none put N/A
Exp. Date (BoNT Treatment) l
/
Month
/
Day
Year
Date
Frontails (Dosage Units)
Annotate Image
Frontalis (Dosage Units)
Glabellar (Dosage Units)
Crow's Feet (Dosage Units)
Brow Lift (Dosage Units)
Bunny Lines (Dosage Units)
Lip Flip (Dosage Units)
DAO (Dosage Units)
Chin (Dosage Units)
Masseter (Dosage Units)
Platysmal Bands (Dosage Units)
Other (Dosage Units)
Topical Antiseptic
Filler Used
Total Syringes Used
Cost Per Unit/Syringe:
Discounts/Coupons
Total Cost of Treatment:
Area(s) Treated
Topical Anesthetic Used
Topicals Used Post Procedure:
Recommended
Patient Signature
Clear
Provider Name
*
Provider Signature
*
Clear
Date
*
/
Month
/
Day
Year
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