Botulinum Toxin Treatment Record Form
Patient Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
-
Month
-
Day
Year
Date
Facial Injury History
Is there any history of facial surgery?
Yes
No
If your answer is "Yes", please describe details:
Is there a recent history of head or facial trauma?
Yes
No
If your answer is "Yes", please describe details:
Have you ever had an adverse reaction to any medicine?
Yes
No
If your answer is "Yes", please describe details:
Treatment Details
Treatment Date:
-
Month
-
Day
Year
Date
Practitioner Name:
Please Select
Select the Products Used in Treatment
Type option 1
Type option 2
Type option 3
Type option 4
Skin texture Details:
Treatment Details:
Reduction in volume notes:
Upload the Before-After Photo
Browse Files
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Additional Notes:
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Should be Empty: