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NP/PA PERFORMING GFE
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Is the PT 18 years of age or older?
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Is Patients parent or legal guardian present
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Does patient have any Medical Conditions?
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If yes, please list:
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Does patient take any medications?
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If yes, please list:
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Does patient have any allergies?
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If yes, please list:
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Is patient pregnant or breastfeeding?
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Notes:
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Taking Accutane?
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Microneedling
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Any adverse reactions?
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If yes, please explain
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History of immune suppression deficiency due to medication disease process
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if yes, please explain
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History of diabetes
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History of inflammatory skin condition?
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if yes, please explain
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Currently taking anticoagulant medications?
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History of keloid scars?
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PRP
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Bleeding or clotting disorder?
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Presence of moles, skin tags or other skin lesions in treatment area
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Neuromodular treatment 2 weeks before or after?
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History of metastatic cancer?
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Dermal Filler 2 weeks before or after?
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Undergoing chemotherapy?
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Acute or chronic skin infection?
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Skin infection or inflammation in or near the tx area?
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Immune suppression or immune deficiency?
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History of poor, slow or abnormal wound healing or keloids?
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Patient Cleared for Following:
• • •
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Standing Orders
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Additional Comments
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Discussion with Patient
• • •
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Patient verbalized understanding to this warning
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Signature of Patient
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Signture of NP
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Signature of Medical Director
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