NEUROTOXIN & FILLER 2024

Injection Date * +

First Name *

Last Name *

Phone Number *

Injector *

KIM DAYAL, NP

SANDRA ROCHA

Brooke Sweet

Adjustment or Fix to injection done within 30 days prior? *

YES

NO

Changes to Medical History last visit *

YES

NO

Has client received injections in the past *

Pre-Injection Photo - EYEBROWS RAISED *

Pre-Injection Photo FROWN *

Pre-Injection Photo BIG SMILE ( CROWS FEET)

Product Lot Number & expiration

FIRST ITEM USED *

Units per injection point

Glabella

2

4

6

Forehead

2

4

6

Crows

2

4

6

Jaw

2

4

6

lip

2

4

6

INJECTABLE	Regular	Insider
Botox	$ 14	$ 12
Jeuveau	$ 11	$ 9
Dysport	$ 5	$ 4
Xeomin	$ 11	$ 9
Daxxify	$ 6	$ 5
Versa	$ 499	$ 424
Juvederm	$ 599	$ 509
RHA	$ 699	$ 594
Radiesse	$ 799	$ 679
half syringe	$ 299	$ 254

SIGN UP THE PERSON

First Item Quantity *

First Item Price Per unit *

Price for Customer *

First Item Total:

0.00

Second Item Used

Second Item Quantity

Second Item Price Per Unit

Second item Price for Customer

First Item Total:

0.00

Comments

Send to Kim for Review

SEND

BOTOX	DYSPORT	KYBELLA	Restalyne
Juvederm	JEUVEAU	VERSA	Bio-Filler
MIC	Xeomin	Daxxify	BOTOX "SPECIAL"
Semaglutide "O"	None

BOTOX	DYSPORT	KYBELLA	Restalyne
Juvederm	JEUVEAU	VERSA	Bio-Filler
MIC	Xeomin	Daxxify	BOTOX "SPECIAL"
Semaglutide "O"	None	RHA

BOTOX	DYSPORT	KYBELLA	Restalyne
Juvederm	JEUVEAU	VERSA	Bio-Filler
MIC	Xeomin	Daxxify	BOTOX "SPECIAL"
Semaglutide "O"	None	RHA