subject_line
First Name
*
Last Name
*
Phone Number
*
Injector
*
KIM DAYAL, NP
SANDRA ROCHA
Injection Date
*
+
Changes to Medical History last visit
*
YES
NO
Has client received injections in the past
*
BOTOX
DYSPORT
KYBELLA
Restalyne
Juvederm
JEUVEAU
VERSA
Bio-Filler
MIC
Xeomin
Daxxify
BOTOX "SPECIAL"
Semaglutide "O"
None
Pre-Injection Photo - EYEBROWS RAISED
*
Pre-Injection Photo FROWN
*
Pre-Injection Photo BIG SMILE ( CROWS FEET)
*
Product Lot Number & expiration
*
FIRST ITEM USED
*
BOTOX
DYSPORT
KYBELLA
Restalyne
Juvederm
JEUVEAU
VERSA
Bio-Filler
MIC
Xeomin
Daxxify
BOTOX "SPECIAL"
Semaglutide "O"
None
First Item Quantity
*
Price
*
Second Item Used
BOTOX
DYSPORT
KYBELLA
Restalyne
Juvederm
JEUVEAU
VERSA
Bio-Filler
MIC
Xeomin
Daxxify
BOTOX "SPECIAL"
Semaglutide "O"
None
Second Item Quantity
Second item Price
Comments
Send to Kim for Review
SEND
Powered by