|
Patient Name and DOB
|
ThermiVa Date
|
|
Pregnancy Test
|
Normal Pelvic and Date
|
|
LMP
|
LMP N/A
|
|
Metal In the Body
|
Allergies
|
|
Before and After Photos
|
Signed informed consent
|
|
Lot Numbers and GPad Location
|
Treatment Area
|
|
Treatment #
|
Zone, Temp, and Time
|
|
|
|
|
Front Standing BEFORE
|
Front Standing AFTER
|
|
Back Standing BEFORE
|
Back Standing AFTER
|
|
Table BEFORE Photo
|
Table AFTER Photo
|
