|
Pregnant?
|
Photograph Taken Documentation
|
|
Allergic to Aspirin?
|
Accutane in the last 6 months?
|
|
Latex Allergy?
|
Cold Sores in the past?
|
|
Baseline Physical Exam
• • •
|
Package
|
|
SELECT ALL IF DOING A PEEL!
• • •
|
Comments on Baseline Examination
|
|
Chemical Peel Done Today
|
|
|
Follow Up
|
|
|
Skincare Recomendations
• • •
|
|
|
Comments:
|
Skin Care Recommendations Other
|
|
Aesthetician/Provider
|
Post Treatment Instructions Give
|
