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Gender
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DOB
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Assessment performed by:
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Office of Assessment
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Where did you find us?
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Contraindications
• • •
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Additional Notes:
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Any other aesthetic procedures to body/notes about them
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Treatment plan
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Areas to be treated
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CoolCore Applicator
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Notes regarding placement of the applicator
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CoolAdvantage Core Applicator
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Notes regarding placement of the applicator
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CoolCurve+ Applicator
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Notes regarding placement of the applicator
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CoolAdvantage Curve+ Applicator
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Notes regarding placement of the applicator
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CoolFit Applicator
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Notes regarding placement of the applicator
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CoolAdvantage Fit Applicator
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Notes regarding placement of the applicator
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CoolMax Applicator
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Notes regarding placement of the applicator
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CoolAdvantage Plus Applicator
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Notes regarding placement of the applicator
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CoolSmooth Pro Applicator
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Notes regarding placement of the applicator
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CoolMini Applicator
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Notes regarding placement of the applicator
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How many treatments needed?
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Promotion used for Pricing/quote given to pt:
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Additional Notes needed/special events coming up
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