|
Pregnant ?
|
No Changes in Medical History
|
|
Changes in Medical History
|
|
|
Botox
|
|
|
Botox
|
|
|
Glabella
|
Units
|
|
Forehead
|
Units
|
|
Crows feet
|
Units
|
|
Botox flexible areas
• • •
|
Serial Number #
|
|
Botox flexible Units
• • •
|
|
|
Filler
|
Filler
|
|
Juvederm Nasolabial
|
Serial Number #
|
|
Juvederm Nasolabial/Marrionette
|
Serial Number #
|
|
Juvederm Upper Lip
|
Juvederm flexible amount
• • •
|
|
Juvederm Upper and Lower Lip
|
Juvederm flexible areas
• • •
|
|
Latisse
|
Latiesse
|
|
Laser Exam
|
|
|
Baseline Exam
• • •
|
Fitzpatrick Classification
• • •
|
|
Select all prior to laser
• • •
|
Comments
|
|
CO2 Laser
|
|
|
CO2 Laser
|
Laser performed by
|
|
Face Dwell Time Settings
• • •
|
|
|
Spacing
• • •
|
Spacing
• • •
|
|
2 passes
|
Spacing
• • •
|
|
Perioral Vertical Lip Lines
• • •
|
Spacing
• • •
|
|
Peri ocular - eyelids - nasal
• • •
|
Comments
|
|
Neck area upper chest area
• • •
|
2 passes
|
|
Laser Hair Removal
|
|
|
Laser Hair
|
|
|
1st Settings Location(s)
• • •
|
1st Power Settings
• • •
|
|
2nd Setting Location(s)
• • •
|
2nd Power Settings
• • •
|
|
3rd Setting Location(s)
• • •
|
3rd Power Settings
• • •
|
|
4th Setting Location(s)
• • •
|
4th Power Settings
• • •
|
|
Power settings
• • •
|
Comments
|
|
Post Instructions
|
|
|
No procedure discussion
• • •
|
No procedure discussion
|
