Cosmetic Neuromodulator (Botulinum Toxin) Injection Procedure Note

Date/Time: [Date and time of procedure]

Patient: [Full name], [DOB]

Location: [Clinic/procedure room]

Injector: [Name], [Credentials]

Procedure Summary

[Brief 1–3 sentence summary including indication/goal, areas treated, product brand name, and total units injected] (Keep concise for at-a-glance context.)

Indication and Baseline Assessment

• Patient-stated goals: [Cosmetic goals]
• Prior neuromodulator history: [Product(s), response/duration, prior complications such as ptosis or asymmetry, dosing patterns] (Include only if relevant; otherwise omit this line.)
• Baseline facial assessment: [Resting/dynamic asymmetry, brow position, frontalis compensation pattern, muscle activity patterns, skin abnormalities at planned sites, other findings affecting treatment plan]
• Photography today: [Yes / No] (If Yes, note storage location.)

Contraindication Screening

(Document explicit Yes/No screening. If any item is positive, document action taken. If any item is not assessed, document that procedure did not proceed.)

Item	Result	Details/Action if Positive
Infection at planned injection sites	[Yes / No / Not assessed]	[Details and action taken]
Known hypersensitivity to botulinum toxin products	[Yes / No / Not assessed]	[Details and action taken]
Neuromuscular disorders (myasthenia gravis, Lambert-Eaton, ALS)	[Yes / No / Not assessed]	[Details and action taken]
Dysphagia or respiratory compromise	[Yes / No / Not assessed]	[Details and action taken]
Pregnancy or lactation	[Yes / No / Not assessed]	[Details and action taken]
Relevant medications (anticoagulants, aminoglycosides, muscle relaxants)	[Yes / No / Not assessed]	[Medication(s) and action taken]

Proceed with procedure: [Yes / No] (If No, document reason and plan.)

Informed Consent

• Nature, purpose, expected benefits and limitations discussed: [Yes / No]
• Alternatives discussed: [Yes / No]
• Material risks discussed (local: bruising, swelling, pain, asymmetry, ptosis; systemic per boxed warning: distant toxin spread causing dysphagia, dysarthria, respiratory difficulty, generalized weakness; rare hypersensitivity): [Yes / No]
• Off-label status discussed: [Yes / No / N/A]
• Onset/peak/duration expectations discussed: [Yes / No]
• Opportunity for questions provided: [Yes / No]
• Written consent signed: [Yes / No]; Location: [Storage location]
• Product-specific Medication Guide provided: [Yes / No / N/A]

Product and Traceability

(Safety-critical fields. If any field cannot be completed, enter "REQUIRED FIELD NOT COMPLETED.")

Product (brand name)	[Brand name]
Generic/nonproprietary name	[Botulinum toxin type]
Vial size	[Units per vial]
Lot number	[Lot number]
Expiration date	[Expiration date]
Diluent	[Type, e.g., preservative-free 0.9% saline]
Volume added	[mL]
Final concentration	[Units per 0.1 mL]
Reconstitution date/time	[Date and time]
Total units injected	[Total units] (Must match Injection Map grand total.)
Units wasted/discarded	[Units]

Vial handled as single-dose per policy.

Procedure Details

Patient positioned [seated / semi-reclined / supine]. Skin antisepsis with [antiseptic agent]. Anesthesia/comfort measures: [none / ice / topical anesthetic / vibration]. Needle: [gauge] G × [length] inch. Injection technique: [intramuscular / intradermal / subdermal] plane. [Safety considerations or deviations from plan with rationale] (Keep narrative brief; specific sites and dosing documented in Injection Map.)

Injection Map

(Document each injection site. Grand total must reconcile with Product and Traceability section.)

Region/Area	Target Muscle	Side	Units	Notes
[Region]	[Muscle]	[L / R / Midline]	[Units]	[Depth, caution areas, or special technique]
[Region]	[Muscle]	[L / R / Midline]	[Units]	[Notes]
[Region]	[Muscle]	[L / R / Midline]	[Units]	[Notes]
[Region]	[Muscle]	[L / R / Midline]	[Units]	[Notes]
[Region]	[Muscle]	[L / R / Midline]	[Units]	[Notes]
Grand Total			[Total units]

Tolerance and Complications

Tolerance: [Well tolerated / Poorly tolerated] (If poorly tolerated, specify: [Details].)

Immediate complications: [None / Bleeding / Bruising / Vasovagal episode / Other] (If present, document interventions: [Interventions performed].)

Status at conclusion: [Stable and ambulatory / Other]

Aftercare and Return Precautions

• Aftercare instructions provided (avoid rubbing/massage of treated areas, activity restrictions): [Yes / No]
• Expected timeline reviewed (onset over days, peak at approximately two weeks, typical duration in months): [Yes / No]
• Return precautions reviewed including urgent symptoms requiring immediate medical attention (difficulty swallowing, speaking, or breathing; generalized weakness; vision changes or diplopia; progressive ptosis; signs of infection; severe allergic reaction): [Yes / No]
• Follow-up: [Timing for assessment/touch-up]

Signature

Injector Signature: [Name, credentials, date/time]