This Botox charting template is a one-page form for documenting a neurotoxin treatment. It has a front face map to mark each injection point with its units, a table of common treatment areas and fields for the product, lot number, expiration date, dilution, consent, photos, follow-up and the provider's signature. Print it from this page or download the PDF.
Botox is a brand name, and it is the name people search for, so the template carries it. The form works for any neurotoxin: write the product your clinic uses in the product field. It is a documentation aid, not a clinical protocol, so follow your state's rules and your medical director on what your charts must contain.
What does the template include?
Each field answers a question that comes up later: who was treated, with what, from which lot, how much, where and with what consent. The areas table lists the forehead, glabella, crow's feet (left and right), bunny lines, lip flip, chin, DAO, masseter (left and right), platysma and a row for anything else.
| Field | Why it matters |
|---|---|
| Client name and date of birth | Two identifiers tie the chart to the right person |
| Visit date and provider | Shows when the treatment happened and who is accountable for it |
| Product | Neurotoxin products are not interchangeable, so name the one used |
| Lot number and expiration date | Traces the batch after a recall or an adverse event |
| Dilution (units per mL) | Shows how the vial was prepared, so the units read correctly |
| Face map | Shows where each point went and how many units it received |
| Areas table, with units and notes | A per-area count that is easy to compare at the next visit |
| Total units | A check against the points on the map and the stock used |
| Consent signed, photos taken | Confirms the records kept outside the chart |
| Follow-up date | Closes the loop with the client |
| Provider signature | Makes the chart final |
How do you fill in the template?
Fill it in during the visit, in this order, so nothing depends on memory at the end of the day.
- Before the client sits down, write the name, date of birth, visit date and provider.
- Check the records. Mark whether consent is signed and photos are taken.
- Record the product, then copy the lot number and expiration date from the vial. If you open a second vial from another lot, add its lot and expiration in the notes.
- Write the dilution in units per mL, the way the vial was reconstituted.
- Mark each injection point on the face map and write its units beside it.
- Fill in the areas table with the units for each area and any notes.
- Add the total units and check that it matches the areas table and the map.
- Set the follow-up date, sign the chart and file it with the client's record the same day.
How do you chart units and points clearly?
Put a number next to every point. A point without units, or units without a point, leaves the next provider guessing.
- Use one mark per injection point and write the units beside it in clear numerals.
- Label sides by the client's left and right. On the front face map, the client's left is on your right.
- Keep left and right in their own rows, even when both sides were treated the same way.
- When you use the Other row, name the area.
- Make the total match the sum of the areas table.
- Correct an error with a single line through it, your initials and the date. Never erase or write over a number.
The template records doses. It does not suggest them. How many units go into each area is the provider's clinical judgment, guided by the product label and the clinic's protocols. For filler and the rest of the record, see our guide to injectable charting.
Why do lot numbers and expiration dates matter?
The lot number ties each treatment to the batch of product used. If a manufacturer recalls a lot, or a client reports an adverse event, the clinic has to say who received that batch and when. The chart is where that answer lives.
The expiration date shows the product was in date on the day of treatment, which matters when a reaction is reviewed. Record both every time, and record both lots when a visit uses two vials. On paper, finding every client who received one lot means reading every sheet by hand.
What are the limits of a paper chart?
A complete paper chart can document a visit. The problems start around it.
- Legibility. Handwritten units and points are easy to misread a year later.
- Lost sheets. Paper gets misfiled, damaged or left in a treatment room.
- No link to inventory. Units on the sheet never leave the stock count, so someone counts by hand.
- Photos and consents in other places. Photos sit on a phone or camera, and consents in another file.
- Harder audits. Answering a recall or a records request means pulling and reading sheets one by one.
When should you move to a digital chart?
Move when the paper costs more time than it saves: when the team hunts for old charts, counts stock by hand, matches lots to clients after the fact or keeps photos and consents somewhere else. Each new provider or location makes those gaps bigger, because more people read the same chart.
In Klinycs, the provider charts on a face map with front, left and right views, and every point records the product, the units and the lot. Signing the note takes those units out of inventory by lot, so stock and chart agree, and locks the note: after signing, it changes only by amendment, and every version is kept. Photos and consents sit in the same client record. For what else to look for, see what a med spa EMR should include.
In the platform