Doctor form

Dr. Amrit Thiara

Patient name

Birthday

Day

Month

Year

Date of treatment

Day

Month

Year

Area treated

Nose

Lips

Chin

Frown Area

Forehead area

Crows Feet

Brows

Undereyes (Tear Trough)

Temple

Mid-face Rejuvenation (Tear trough & Mid-cheek)

Cheeks

Nasolabial folds

Piriform fossa

Gummy smile

Masseter muscle

Downturned Corners

Full Face

Both Hands

Neck

Decolletage

Arms

Stomach

Legs

Perioral/ smokers lines

Chin pebbling

Pre jowl

Jawline

Underarms

Upper & Lower Lids

Total number of Syringes used (attach sticker/s here) Batch Lot Number/Expiry

Botulinum Toxin used:

Yes

No

Hyalase used:

Yes

No

Any Complications?

Yes

No

Other

Detailed Treatment Notes

Draw the treated areas

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