Title Mrs.Mr.

Title ---Dr. med.Prof. Dr. med.Dipl. med.Other

First name

Name

Hospital/clinic

Treatment person SelfOther treatment personUnknown

Speciality General medicineDermatologyPlastic surgeryENTOphthalmologyDentistryOther
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Street

Post code

Town/city

Tel.

Mobile

Email *

Injected material/treatment BotulinumFillerThreadsAutologous fatLaser
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Filler material AbsorbableNon-absorbable

Threads ---StarChromaRainbowVenusHappy LiftPolylactic acidSilhouetteAptos

If known: Product name/degree of interconnections

If known: Batch number

Patient FemaleMale

Patient age

Allergies

Does the patient take any regular medications? NoYes

Secondary diseases ---DiabetesAutoimmune diseasesDisorders of the thyroid glandDermatological diseasesOther
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Reason for treatment Wrinkle treatmentScar correctionLoss of volumeOther
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When was the treatment carried out?

When did side effects occur?

Treatment areas ForeheadChin surfaceChin edgeCrows feetCorner of mouthNasolabial foldUpper lipLower lipCheek volumeCheek wrinkleFrown wrinklesOther
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Had the patient previously received treatment with a different filler? NeinJa

Side effects HaematomaErythemaOedemaAngioedemaGranulomaHardening of materialBlue linesAbscess
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Severity of side effect Slight- Haematoma- Oedema- Erythema- Blue linesModerate- Angioedema- Hardening of material- InflammationSevere- Abscess, sterile- Abscess, infectious- Granuloma- Embolism- Thrombosis- Blindness
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Doctor's assessment of the cause for side effects DoctorPatientProduct

Treatment of side effects AntibioticsSteroidsHylaseSurgical abscess drainageOther
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Further information on treatment and patient progress

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Title Mrs.Mr.

First name

Name

Gender femalemalediverse

Date of Birth

Street

Post code

Town/city

Telephone

Email *

Preparation used BotulinumFillerThreadsOwn-fatLaserOther

When was the treatment carried out?

Who carried out the treatment? DoctorCosmeticianNon-medical practitioner

Side effects BruisingReddeningSwellingHardening of materialNoduleAbscessEmbolismBlood clotInflammation
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When did side effects occur?

Estimation of severity of side effect ---SlightModerateSevere

Previous treatment of side effects

Allergies NoYes

Comment

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