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Templates, Clinical notes, Aesthetics

Aesthetics initial consultation note template

A aesthetics initial consultation note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Initial consultation note

TemplateAesthetics

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Aesthetics initial consultation note

1Presenting complaint

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.

2History of the presenting complaint

  • The concern the patient wants to address, and their expectations.
  • Previous aesthetic treatments, with dates and any reactions.

3Past history, medicines and allergies

  • Medical history relevant to treatment, including neuromuscular conditions, pregnancy and breastfeeding.
  • Current medicines and allergies.

4Social and family history

  • Occupation, smoking, alcohol and anything else relevant to the complaint.
  • Family history where it changes risk or management.

5Examination

  • Facial assessment at rest and in animation, with photographs taken with consent.
  • Skin condition at the treatment sites.

6Impression

  • Suitability for treatment, and any reason to defer.
  • Whether the patient's expectations are realistic.

7Plan

  • Investigations requested, and who will follow up the result.
  • Treatment agreed, as prescribed in the prescribing record.
  • Referrals made, and what was explained to the patient.

8Safety-netting

  • What should prompt the patient to get back in touch, and how.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Initial consultation note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Aesthetics initial consultation note

1Presenting complaint

  • Wishes to soften forehead lines.00:25

2History of the presenting complaint

  • One previous treatment twelve months ago, no adverse reaction.01:15

3Past history, medicines and allergies

Completed by the clinician from the record.

4Social and family history

Completed by the clinician from the record.

5Examination

  • Dynamic horizontal forehead lines, mild static lines at rest. Photographs taken with consent.03:20

6Impression

  • Suitable for treatment. Expectations discussed and realistic.04:40

7Plan

  • Treatment today. Review in two weeks.05:30

8Safety-netting

  • Advised to contact the clinic with eyelid droop or persistent headache.06:10

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in an aesthetics initial consultation note?

Presenting complaint, History of the presenting complaint, Past history, medicines and allergies, Social and family history, Examination, Impression, Plan and Safety-netting. Each section on this page lists what belongs in it, written for aesthetics.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

Come back to the note, written and ready to sign.

See the wai scribe write an aesthetics initial consultation note on your own structure, in a 15 minute video call.