(Indicate the exact injection sites/dosages on the diagram above)

Patient Name: ______________________________________ Date of treatment: ___________________________

First Treatment? YES ☐ NO ☐ If NO - Date of last Treatment: _____________________________________

Areas of concern / Clinical Notes: ____________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Medical History Checked: ☐ Findings: ______________________________________________________________

Consent Obtained: ☐ Photographs Taken: ☐ Lot/Batch No.________________________________________

Product(s) Used: __________________________________________________________________________________

BTx Dilution Used: ________________________________________________________________________________

Total Dose(s) Used: ______________________________________________________________________________

Post-Op Instructions Given ☐ Anaesthetic Used: _________________________________________________ Injection Techniques Used: _________________________________________________________________________ Dentist Name & Signature: ________________________________________________

Facial Injectable Treatment Record