|
Botox
|
|
|
Botox 33 Units
|
Serial Number #
|
|
Botox 50 Units
|
Serial Number #
|
|
Botox flexible Units
• • •
|
Botox flexible areas
• • •
|
|
Serial Number #
|
Botox Comments
|
|
|
|
|
Radiesse Injection Cheek
|
Serial Number #
|
|
Radiesse Comments
|
|
|
Juvederm Nasolabial
|
|
|
Juvederm Nasolabial
|
Serial Number #
|
|
Juvederm Nasolabial/Marrionette
|
Serial Number #
|
|
Juvederm Upper Lip
|
Serial Number #
|
|
Juvederm Upper and Lower Lip
|
Serial Number #
|
|
Juvederm flexible amount
• • •
|
Juvederm flexible areas
• • •
|
|
Serial Number #
|
Juvederm Comments
|
|
|
|
|
Comments
|
Serial Number #
|
|
Latiesse
|
|
|
|
Comments
|
|
DOT Laser
|
Spacing
• • •
|
|
Face Dwell Time Settings
• • •
|
Comments
|
|
2 passes
|
Spacing
• • •
|
|
Perioral Vertical Lip Lines
• • •
|
|
|
2 passes
|
Spacing
• • •
|
|
Peri ocular - eyelids - nasal
• • •
|
Spacing
• • •
|
|
Neck area upper chest area
• • •
|
Comments
|
|
|
|
|
Laser Hair
|
|
|
Laser Hair
|
Comments
|
|
Select all prior to laser
• • •
|
Baseline Exam
• • •
|
|
Fitzpatrick Classification
• • •
|
Pregnant ?
|
|
Accutane use last 6 months
|
Recent Marked Sun Exposure
|
|
Recent Herpes Outbreak ?
|
Power settings
• • •
|
|
1st Settings Location(s)
• • •
|
2nd Power Settings
• • •
|
|
2nd Setting Location(s)
• • •
|
3rd Power Settings
• • •
|
|
3rd Setting Location(s)
• • •
|
4th Power Settings
• • •
|
|
4th Setting Location(s)
• • •
|
Laser performed by
|
|
Post Instructions
|
|
|
|
Comments
|
|
Ear Lobe Repair
|
|
|
|
Seroma Catheter Amount
• • •
|
|
Seroma Catheter Location
• • •
|
Comments
|
|
|
Seroma Amount
• • •
|
|
Seroma Aspiration
• • •
|
Comments
|
|
|
Size Patient Liked
• • •
|
|
Needle Deflation Implant
• • •
|
Comments
|
|
|
|
|
Skin Lesion
|
Skin Lesion Diagnosis
• • •
|
|
Skin Lesion Location
• • •
|
Comments
|
|
|
Skin Lesion 2 Diagnosis
• • •
|
|
Skin Lesion 2 Location
• • •
|
Comments
|
|
|
Skin Lesion 3 Diagnosis
• • •
|
|
Skin Lesion 3 Location
• • •
|
Comments
|
|
|
|
|
|
Scar length (cm)
|
|
Scar Revision Location
• • •
|
Comments
|
|
|
Debridement length (cm)
|
|
Debridement Location
• • •
|
Comments
|
|
|
Type packing /no packing
• • •
|
|
I&D abscess
• • •
|
Comments
|
|
|
|
|
|
Cleaned with
• • •
|
|
Skin Laceration Location
• • •
|
Prepped with
• • •
|
|
Foreign Material in Wound
• • •
|
Laceration Length (cm)
|
|
Closure Performed with
• • •
|
Comments
|
|
|
|
|
|
No procedure discussion
|
|
No procedure discussion
• • •
|
|
|
Seek 2nd Opinion
|
|
