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Assessment
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Problem
• • •
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Notes
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Plan
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Chemical Peel Used
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Lot Number
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Ex. Date
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Areas Treated
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Face Diagram
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Face
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Number of Passes
• • •
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Forehead
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Number of Passes
• • •
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Cheeks
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Number of Passes
• • •
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Nose
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Number of Passes
• • •
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Chin
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Number of Passes
• • •
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Neck
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Number of Passes
• • •
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Chest
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Number of Passes
• • •
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Other
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Number of Passes
• • •
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Post Treatment
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Complications
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Possible Complications
• • •
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Follow-Up
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Follow-up Comments
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Treatment Provider
• • •
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Supervising Clinician
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Medical Director Consulted
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Comments
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