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Chemical Peel
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Chemical Peel
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Peel Consent Form
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Photograph Taken Documentation
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Pregnant?
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Accutane in the last 6 months?
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Allergic to Aspirin?
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Cold Sores in the past?
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Latex Allergy?
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Package
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Baseline skin Exam
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Additional Comments on Baseline Examination
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SELECT ALL IF DOING A PEEL!
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Chemical Peel Done Today
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Follow Up
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Skincare Recomendations
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Skin Care Recommendations Other
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Chemical Skin Peel Additional Comments:
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Post Treatment Instructions Given
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Hydrafacial
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Hydrafacial
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Hydrafacial Consent signed and copy given to patient - first visit
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Hydrafacial Consent - first visit
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Consent reviewed with client at each visit
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Risks discussed
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Hydrafacial treatment level
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Hydrafacial Additional products/services
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Followed program instructions with device
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What appropriate differences in procedure were done
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Microneedle Procedure
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Microneedle
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Risks discussed
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Microneedle Procedure Consent Signed
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Microneedle without biologics
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Microneedle with Biologics (PRP/Exosomes)
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Biologics
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Post Procedure examination
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Post procedure instruction sheet given to the client
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Botox/Dysport
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Aesthetic Botulinum Toxin
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Botulinum Toxin Risk Statement
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Botulinum Toxin Consent Form Signed
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Glabella
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Glabella Units
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Forehead
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Forehead Units
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Crows feet
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Crows Feet Units
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Other (additional area)
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Botox diagram
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Botulinum Toxin Brand
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Expiration
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Lot #
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Post procedure bruising
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Fillers
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Fillers
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Understanding of Filler Risks
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Filler Consent Signed
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Consents Signed
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Injectable filler consent
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Injection diagram
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Juvederm Volbella
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Volbella Lot #
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Volbella Lot #
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Volbella Lot #
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Juvederm Vollure
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Vollure Lot #
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Vollure Lot #
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Vollure Lot #
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Juvederm Voluma
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Amount
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Voluma Lot #
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Voluma Lot #
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Voluma Lot #
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Voluma Lot #
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Voluma Lot #
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Voluma Lot #
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Juvederm Ultra Plus
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Juvederm Ultra Plus Lot #
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Juvederm Ultra Plus Lot #
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Juvederm Ultra Plus Lot #
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Juvederm Ultra
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Juvederm Ultra Lot #
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Juvederm Ultra Lot #
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Juvederm Ultra Lot #
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Hyaluronidase Location
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Amount
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Restylane Lyft
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Restylane Lyft Lot #
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Restylane Lyft Lot #
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Restylane Lyft Lot #
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Restylane Lyft Lot #
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Restylane Lyft Lot #
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Restylane Defyne
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Restylane Defyne Lot #
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Restylane Defyne Lot #
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Restylane Defyne Lot #
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Restylane Defyne Lot #
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Restylane Defyne Lot #
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Restylane Refyne
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Amount
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Restylane Refyne Lot #
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Restylane Refyne Lot #
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Restylane Refyne Lot #
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Restylane Refyne Lot #
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Restylane
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Amount
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Restylane Lot #
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Restylane Lot #
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Restylane Lot #
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Restylane Lot #
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Restylane 0.5 cc
• • •
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Restylane 0.5cc Lot #
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Restylane 0.5cc Lot #
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Restylane 0.5cc Lot #
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Laser Hair Removal
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Laser Hair Removal
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Small Area
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Medium Area
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Large Area
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Notes
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Signature Log 1
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Purchase More Treatments
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Medium Area
• • •
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Small Area
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Signature Log 2
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Large Area
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Notes
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Purchase More Treatments 2
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Medium Area
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Small Area
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Signature Log 3
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Large Area
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Notes
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Purchase More Treatments 3
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Medium Area
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Small Area
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Signature Log 4
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Large Area
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Notes
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