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Patient Case Submission
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Date of Level 2 Training
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Date of Treatment
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Date of Follow Up
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Botulinum Toxin
Areas of Patient Concern (Botulinum Toxin)
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Treatment Recommendations
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Botulinum Toxin Brand Used
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# Units Used
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Was a follow up treatment needed for optimal results?
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10 - Completely Satisfied
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Dermal Fillers
Areas of Patient Concern (Fillers)
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Treatment Recommendations (Fillers)
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Dermal Filler Brand Used
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Type of anesthetic used?
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Was a follow up treatment needed for optimal results?
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Rate your patient treatment satisfaction from 1-10
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1 - Very Poor
2
3
4
5
6
7
8
9
10 - Completely Satisfied
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