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RN on Duty:
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Skin Type
• • •
|
|
LASER DEVICE USED
• • •
|
Client consents to no changes in medical history/medications/skin tone
|
|
Pregnant?
|
Breastfeeding
|
|
Taking Accutane?
|
Taking Retin-A/Retinol or Glycolic Acid?
|
|
Taking Antibiotics?
|
Razor Fee
|
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Any tattoos/ no tattoos
|
|
|
Reviewed prior treatment:
|
Comments for prior treatment
|
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Areas Of Treatment
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Areas Of Treatment
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Areas Of Treatment
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Areas Of Treatment
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Areas Of Treatment
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Areas Of Treatment
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Touch Up
• • •
|
Energy
• • •
|
|
COMMENTS
|
ALEX/YAG
• • •
|
|
Treatment Notes
• • •
|
Additional Notes:
|
|
Post LHR Instructions Given
|
Physician Signature
|
