Ethereal Glow Aesthetics — Consultation Form

Patient Notes

Patient Goals

Patient Concerns

Primary Concerns

Treatment History

Medical Screening

Screening ItemResponseNotes / Details
Known allergies (latex, lidocaine, hyaluronidase)
Current medications (including blood thinners, supplements)
Pregnancy or breastfeeding
Autoimmune or neuromuscular disorders
Active skin infection / cold sores
Bleeding / clotting disorders
Prior cosmetic surgery in treatment area
Permanent filler history

Facial Assessment

Zone Observations

Clinical Findings

Contributing Factors



Personalized Treatment Plan Builder

Treatments Performed Today


Treatment Notes

Neurotoxin Documentation

Area Product Units Notes
Glabella
Frontalis
Crow's Feet (L/R)
DAO / Chin
Lip Flip / Gummy Smile
Nose / Bunny Lines
Masseter (L/R)
Platysma / Neck
Total Units: 0

Dermal Filler Documentation

Area Product Syringes Notes
Temples
Lips
Nasolabial Folds
Cheeks / Midface
Tear Trough
Jawline
Marionette Lines
Chin / Chin Shadow
Neck
Hands
Total Syringes: 0

Product Details

Product/Brand
Lot Number
Expiration Date
Dosage units of neurotoxin reconstituted with mL of bacteriostatic normal saline.

Product Details

Product/Brand
Lot Number
Expiration Date

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Safety

Conservative dosing approach
Avoided high-risk vascular zones
Aspiration performed
Slow injection technique
Hyaluronidase on hand
Anatomy reviewed pre-injection

Technique

Layered technique utilized
Linear threading
Retrograde fanning
Cannula used
Needle used
Bolus technique
Microdroplet technique

Assessment

Symmetry assessed pre/post
Photos taken pre/post
Patient tolerated well
No adverse events
Ice applied post-procedure
Patient verbalized understanding

Post-Treatment

SOAP Note

SSubjective
OObjective
AAssessment
PPlan

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