L Aesthetics
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Dysport Patient Record
Patient Name
(Required)
First
Last
Treatment Date
(Required)
DD slash MM slash YYYY
Last injection
(Required)
DD slash MM slash YYYY
Reconstitution date
(Required)
DD slash MM slash YYYY
Batch number
(Required)
Expiry date
(Required)
DD slash MM slash YYYY
Name
(Required)
First
Last
Date
(Required)
DD slash MM slash YYYY
Total dose injected
(Required)
Dilution
(Required)
2.5mL per 500 unit
Other
Observations / areas of priority for patient
(Required)
Other
Patient consent / cooling off period
Pre treatment photo
Comments
Practitioner
Prescribing doctor
Follow-up appointment
DD slash MM slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Treatment Area
Please click edit and annotate the area being treated
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