Aesthetic Consultation Form

Patient Information

• Name: Sarah Jenkins
• Date of Birth: 14/06/1982
• Contact Information: 07700 900456, 42 High Street, Guildford, GU1 3EL (NHS: 485 729 1034)

Consultation Details

• Date of Consultation: 24/10/2023
• Reason for Visit: Aesthetic consultation for upper face rhytids and mid-face volume loss.
• Medical History: Mild asthma; occasional herpes labialis. No Hx of keloid scarring, autoimmune disease, or BDD. Not pregnant/breastfeeding.
• Previous Surgeries: Laparoscopic appendicectomy (2015).
• Current Medications: salbutamol (Ventolin®) 100 mcg INH PRN.
• Allergies: NKDA. No known allergy to lidocaine or bee/wasp stings.
• Social History: Non-smoker, EtOH 4 units/wk, works as a marketing director.

Aesthetic Concerns

• Areas of Concern: Deepening glabellar lines, horizontal forehead lines, and mild flattening of the malar eminence bilaterally.
• Desired Outcomes: Softening of upper face dynamic wrinkles and subtle restoration of cheek volume for a refreshed, natural look.
• Previous Aesthetic Treatments: Botulinum toxin to upper face 18 months ago (good result, no complications). Naive to dermal fillers.

Examination Findings

• Skin Type: Fitzpatrick Type II, Glogau Scale Type II (wrinkles in motion).
• Skin Condition: Mild photoaging, good skin elasticity, mild dehydration, no active infection or dermatoses at proposed injection sites.
• Other Findings: Strong corrugator and procerus activity; moderate frontalis hyperkinesia. Mild static glabellar line at rest. Mild volume deficit in the deep medial cheek fat pads bilaterally. Facial nerve function intact.

Treatment Plan

• Recommended Treatments: 1. Botulinum toxin type A (Bocouture®) 20 units IM to glabella and 10 units IM to frontalis. 2. Hyaluronic acid dermal filler with lidocaine (Juvéderm® Voluma) 1 mL total (0.5 mL per side) supraperiosteal bolus/fanning to zygomatic arch/malar region. Prophylactic aciclovir 200 mg PO 5x/day for 5 days advised if proceeding with perioral treatments in future (not required today).
• Expected Results: Reduction in dynamic upper face rhytids within 10–14 days, lasting 3–4 months. Immediate subtle lift and contour restoration to mid-face, lasting 12–18 months.
• Potential Risks and Side Effects: Bruising, swelling, erythema, tenderness, asymmetry, headache, eyelid/brow ptosis, infection, granuloma, anaphylaxis, and vascular occlusion (skin necrosis/blindness).
• Follow-Up Plan: Review in 14 days at 11:00 to assess toxin efficacy and filler integration; top-up PRN.

Patient Consent

• Consent Given: Yes (verbal and written informed consent obtained; cooling-off period discussed and waived by pt for toxin, booked filler for next week).
• Date of Consent: 24/10/2023

Clinician Information

• Clinician Name: Dr James Vance, MBBS, MRCGP
• Clinician Signature: J. Vance
• Date: 24/10/2023 14:30