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Where did you find us?
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Which specialists do you see?
• • •
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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Equipment 1
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Handpiece
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Area(s)
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Equipment 1
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Handpiece
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Area(s)
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Reason for visit
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Other
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Sun Exposure
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Initials
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Medical/Medication Changes?
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Initials
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Recent injection?
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When?
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Initials
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Test Spot
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Area
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Response
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Setting
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Tech Initials
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Area treated: FACE
• • •
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Other
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Area treated: BODY
• • •
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Clinical endpoint
• • •
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Patient Tolerance
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PFE?
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Post Care reviewed?
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SPF?
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Post Ice?
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Hydrocortisone
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Notes
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