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Client Name
Treatment Date
Injector Name
ALLERGIES
Any changes to medical condition?
Yes
No
If yes, for details please
Any new medications?
Yes
No
If yes, please list
Any new allergies or sensitivities?
Yes
No
If yes, for details please
Are you pregnant, or planning on becoming pregnant in the next three months?
Yes
No
If yes, for details please
Are you breast feeding?
Yes
No
Baseline / skin / Pre-existing Asymmetry :
Precious Outcome
Goal for today / Expectation
Recommendation
Treatment Plan
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