Exam
• • •
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Other
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Skin Type
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Comment
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Pregnant
|
Comments
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Breast Feeding
|
Comments
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History of melanoma
|
Comments
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Melasma
|
Comments
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Pacemaker/AICD
|
Comments
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Accutane use
|
Comments
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Diabetes
|
Comments
|
History of Herpes
|
Comments
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Thrombophlebitis
|
Comments
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History of Keloid scarring
|
Comments
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Smoker
|
Comments
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Allergy to previous filler/neurotoxin
|
Comments
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Diagnosis
• • •
|
Comments
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Treatment Option
• • •
|
Comments
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Medications
|
Allergies
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Signature
|
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RN Initials
|
Date
|
M.D./NP Initials
|
Date
|
New Field
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New Field
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