Medical Aesthetics Consultation & Treatment Plan Note

Date/Time: [Date and time of encounter]

Location: [Clinic/site name]

Encounter Type: [new consult / follow-up]

Clinician(s) and Role: [Name(s), credentials, and role(s)]

Source of History: [patient / caregiver / chart / other]

Interpreter: [not used / used — language and modality] (Include details only if interpreter was used)

Photo Documentation Status: [planned / performed today / declined]

Chief Aesthetic Concern

[Patient's stated concern(s) with direct quote when helpful]

Goal category: [rejuvenation / correction / prejuvenation / maintenance / event-driven]

Aesthetic Goals & Success Criteria

(Order by patient priority; keep concise and decision-relevant)

• [Patient-stated priority #1]
• [Patient-stated priority #2] (Include additional priorities as applicable)
• [Target timeline, if relevant]
• [Tolerance for downtime and risk]
• [Budget constraints, if clinically relevant]
• [Definition of success with realistic limitations] (If patient cannot articulate, document this and the approach used to clarify goals)

Relevant History

(Include only information that affects safety, modality selection, or aftercare)

• [Bleeding/bruising risk factors with relevance]
• [Neuromuscular disorders relevant to neuromodulator use]
• [Autoimmune/inflammatory conditions relevant to planned modalities]
• [Keloid/hypertrophic scarring history]
• [HSV history and prophylaxis plan if perioral procedures or resurfacing considered]
• [Active skin infection/inflammation in treatment areas]
• Pregnancy/breastfeeding status: [pregnant / not pregnant / breastfeeding / not assessed] (Do not infer; document "not assessed" if unknown and relevant modalities are planned)
• [Immunosuppression or wound-healing risk factors]
[Allergies relevant to proposed products/materials]
• [Current medications affecting risk, selection, or aftercare]
• [Lifestyle factors materially affecting planning: smoking/vaping, sun exposure, skincare regimen, occupational constraints] (Include only if they impact modality choice or aftercare)

Prior Aesthetic Procedure History

(Timeline-style; include approximate dates, response, duration, and complications)

• Toxin: [Dates/frequency, response/duration, complications]
• Filler: [Type if known / "type unknown"], [Sites], [Dates], [Response/duration], [Complications] (If type unknown, document uncertainty and clinical impact)
• Threads: [Details and tolerance]
• Lasers/IPL/energy devices: [Device/modality], [Dates], [Response/complications]
• Peels/microneedling: [Agent/device], [Dates], [Response]
• Surgery/fat transfer/implants: [Procedure], [Dates], [Outcomes/complications]

Expectation Screening

(Include only if concerns exist or formal screening tool was used)

[Concerns for unrealistic expectations or appearance preoccupation] [Screening tool used and result, if applicable] [Decision: proceed / stage / defer / decline] [Counseling provided and patient response]

Focused Aesthetic Exam

(Bulleted findings by region with laterality and severity; include Fitzpatrick phototype when energy-based devices are considered)

• General: [Overall appearance, skin quality] Fitzpatrick phototype: [I / II / III / IV / V / VI]
• Upper face: [Dynamic vs static rhytids, volume, brow position, periorbital findings]
• Midface: [Malar volume, tear troughs, nasolabial folds, symmetry]
• Lower face/jawline/chin: [Marionette lines, jowling, contour, chin projection]
• Lips/perioral: [Vermilion show, lip volume/shape, perioral lines]
• Neck/submental: [Skin laxity, platysmal bands, submental fullness]
• Texture/scars/pores: [Texture quality, acne scarring, pore size]
• Photodamage/pigment/vascular: [Lentigines, melasma, erythema, telangiectasias, other lesions]
• Photos: [Consent obtained / declined], [Views obtained], [Storage location] (If declined, document refusal)

Assessment

(Prioritize by patient goals and clinical sequencing dependencies)

[Problem 1 label]

Severity: [mild / moderate / severe]

Key findings: [Exam findings supporting this problem]

Pertinent negatives: [Findings that alter treatment selection or safety] (Include only if decision-relevant)

[Problem 2 label]

(Add additional problems as applicable, following same structure)

Treatment Plan

(Organize by problem; use decision-ready language)

[Problem 1]: [Patient-facing goal]

• Options reviewed: [Options discussed including no treatment]
• Recommended approach: [Modality and rationale linked to goals and risk profile]
• Staging/sequencing: [Timing, number of sessions, dependencies, intervals]
• Key risks and longevity: [Material risks, realistic duration expectations]
• Contraindications/risk mitigation: [Contraindications checked and mitigation steps]
• Patient decision: [Patient elected / deferred / declined...]
• Follow-up: [Timing and objective]

[Problem 2]: [Patient-facing goal]

(Repeat structure for additional problems)

Counseling & Consent

[Risks, benefits, and alternatives reviewed; questions addressed; understanding confirmed] [Off-label discussion: conducted / not applicable] [Written materials provided: specify or none] [Consent status: obtained / not obtained] (If treatment declined, document refusal and counseling; if consent not obtained, note no elective procedure performed)

Follow-up & Safety-Net

• Follow-up: [Interval and objective]
• Urgent concerns: [How to reach clinic/after-hours contact]
• Red flags reviewed: [Vision changes, severe pain, blanching after filler; infection signs after resurfacing] (Include when relevant to procedures planned or performed)

Procedures Performed Today

(Include this section only if at least one procedure was performed; omit entirely otherwise)

[Procedure name] — [Indication linked to Assessment]

• Anatomic site(s): [Sites with laterality]
• Pre-procedure verification: [Time-out completed at time]
• Skin preparation: [Agent and method]
• Anesthesia: [topical / local / nerve block / none] [Agent and dose if applicable]
• Materials/traceability:
  • Injectables: [Product], [Concentration], [Total dose/volume], [Dilution if applicable], [Needle/cannula], [Lot #], [Expiration], [Administered by]
  • Energy devices: [Device], [Settings: wavelength, fluence, pulse duration, spot size, passes], [Treatment mapping], [Eye protection]
  • Peels: [Agent], [Concentration], [Coats], [Endpoints], [Neutralization], [Contact time]
• Technique: [Description sufficient for replication]
• Immediate outcome: [Tolerance and response]
• Complications: [none / specify with actions taken]
• Post-procedure instructions: [Key instructions and restrictions given]
• Return precautions: [Warning signs and how to seek help]
• Disposition: [Follow-up timing and next step]

(Omit sections that do not apply. Do not infer pregnancy status, anticoagulant use, allergy status, or prior filler type—document explicitly or note as "not assessed" when clinically relevant.)