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L Aesthetics
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Dysport Patient Record
Patient Name
(Required)
First
Last
Treatment Date
(Required)
Last injection
(Required)
Reconstitution date
(Required)
Batch number
(Required)
Expiry date
(Required)
Name
(Required)
First
Last
Date
(Required)
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
Time
Hours
:
Minutes
AM
PM
AM/PM
Treatment Area
Please click edit and annotate the area being treated
