Care Directive: I have conducted an assessment of the patient’s cosmetic concerns, and will proceed with treatment of the following:

Patient: _____________________________________________
Condition/Date: _________________________________
Location(s) Product Amount: _______________________________
FACE
NECK
HANDS / PALMS FOR HYPERHYDROSIS
AXILLA FOR HYPERHYDROSIS
Botox , Xeomin, Nuceiva
Up to:

200 Units

Dermal Filler Revanesse Kiss/Ultra/Contour/ Shape Belotero Balance/Intense/Volume Radiesse Restylane

Dilution : _____________ Other : ________________
Up to:
5 mL

Deoxycholic acid 10mg/mL, or Phosphatidylcholine 10mg/mL -specify product name
Up to:

___________mL

Other product (monthly) -Vitamin B complex 1 ml injection SC/IM -Lipotropic cocktail 1 ml injection SC/IM
Product: __________________
Up to:
___________mL

Myself or my agent have explained the potential complications and contraindications of the treatment in question, and have obtained relevant written consent for the required procedure. I authorize and require that myself or my agent proceed with photography of a pre-treatment photo. This order is good for a year.
I appoint as my agent, Hanan Atwi RN, whose signature below represent his/her understanding of the directives and limitations of the care plan outlined above.

 

Signed:
_______________________ (agent) _______________________(medical director)