Case Support Form
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Practitioner Name
(Required)
First Name
Last Name
Practitioner Email
(Required)
Practitioner Cell Phone #
(Required)
Practitioner Type
(Required)
Dentist
Physician
Nurse
Pharmacist
Naturopath
Other
Patient Name
(Required)
First Name
Last Name
Patient Age
(Required)
Date of Treatment
(Required)
MM slash DD slash YYYY
Treatment Areas (Select all that apply)
(Required)
Glabella
Frontalis
Orbicularis Oculi
TMD
MFE
Lower Face
Neck/Platysma
Other
Product Used
(Required)
Botox
Dysport
Xeomin
Other
Before Photos – Relaxed
(Required)
Accepted file types: jpg, jpeg, png, gif.
Example Photo:
Before Photos – Dynamic
(Required)
Accepted file types: jpg, jpeg, png, gif.
Example Photo:
Marked Photos – Relaxed
(Required)
Accepted file types: jpg, jpeg, png, gif.
Example Photo:
Marked Photos – Dynamic
(Required)
Accepted file types: jpg, jpeg, png, gif.
Example Photo:
2-Week After Photos – Relaxed
(Required)
Accepted file types: jpg, jpeg, png, gif.
Example Photo:
2-Week After Photos – Dynamic
(Required)
Accepted file types: jpg, jpeg, png, gif.
Example Photo:
Treatment Notes
(Required)
Comments/Questions
(Required)
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