|
RN on Duty:
|
|
|
Pregnant?
|
Breastfeeding
|
|
Taking Accutane?
|
Taking Rein-A/Retinol or Glycolic Acid?
|
|
Active Acne/Open Lesions
|
Recent Sun Exposure?
|
|
Signature Of Patient
|
Comments:
|
|
Depth of Microneedling
|
Area(s) Treated
• • •
|
|
Passes
|
Other:
|
|
Depth of Microneedling
|
Area(s) Treated
• • •
|
|
Passes
|
Other:
|
|
Depth of Microneedling
|
Area(s) Treated
• • •
|
|
Passes
|
Other:
|
|
Depth of Microneedling
|
Area(s) Treated
• • •
|
|
Passes
|
Other:
|
|
Signature of Medical Director
|
Additional Notes:
|
