MLP Consent
|
ProFx Consent
|
Resurfacing treatment counseled?
|
Concerns
• • •
|
No Contraindications are present
|
|
Pt report suspicious lesion?
|
Additional Comments
|
HSV Prophylaxis
|
|
|
|
Fitzpatrick Skin Type
• • •
|
|
Skin Baseline Exam
• • •
|
Skin Baseline Exam: Comment
|
Suspicious lesions?
|
Suspicious lesion comment
|
Pre Treatment Photo 1
|
Pre Treatment Photo 2
|
Pre Treatment Photo 3
|
Pre Treatment Photo 4
|
Treatment Comments
|
|
|
|
Pre-medications
|
Medications
• • •
|
BLT Topical
• • •
|
Local Anesthesia
• • •
|
|
|
Laser Device Used
• • •
|
|
Area Treated 1
• • •
|
Wavelength 1
• • •
|
Laser Energy Used 1
• • •
|
|
Area Treated 2
• • •
|
Wavelength 2
• • •
|
Laser Energy Used 2
• • •
|
|
Area Treated 3
• • •
|
Wavelength 3
• • •
|
Laser Energy Used 3
• • •
|
|
Treatment Comments
|
|
|
|
Post Treatment
• • •
|
|
Complication?
|
Complications comment
|
|
|
Laser done by
• • •
|
Follow Up
|
Post Laser Instructions Given
|
|
Discharged in care of driver
|
|