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Patient name
*
Date of Birth
*
Doctor
Dr. Amrit Thiara
Dr. Haroon Ashraf
Dr. Richard Devine
Dr. Iram Parwaiz
Harpreet Thiara
Date of treatment
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
Dermal Filler used
Intraline
Teosyal Redensity 2
Teoxane
Profhilo
Juvederm
Sunekos
Botulinum Toxin used:
Yes
No
Lot Number
Expiry date
Hyalase used:
Yes
No
Lot Number
Expiry date
Patch test performed?
Any Complications?
*
Yes
No
Other
Detailed Treatment Notes
*
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What is the nature of the medical condition?
*
Premature ageing
Static line formation
Facial volume loss
Premature menopause related ageing
Migraine/Bruxism
Sun damage/spots
Skin laxity
Hyperhydrosis
Deformity/irregularity of feature(s)
Scars
Pigmentation
Other
None
Select symptoms description:
*
Physical
Psychological
Both
Select & describe in brief the symptoms the patient is experiencing as a result
*
Low self-esteem
Lacks confidence
Loss of self image
Loss of self identity
Depressed
Anxious
Stressed
None
Other
Describe briefly below the recommended treatment programme:
*
Botox
Dermal Fillers
Profhilo
Sunekos
Hyalase
Not suitable
Is the primary purpose of the treatment the protection, maintenance restoration of the health of the client?
*
Yes
No
Doctor
*
Dr. Amrit Thiara (7447741)
Dr. Haroon Ashraf (7645907)
Dr. Richard Devine (7411397)
Dr Iram Parwaiz (7263774)
Date
*
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