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Procedure Performed:
• • •
|
Consent Signed & Reviewed With Patient
|
|
Area Treated / Units or mLs per Area:
|
Standing Delegation Order Prescribed by Provider?
|
|
Skin Prep:
|
Patient Provided with Post-Tx & Emergency Instructions
|
|
Anesthesia:
• • •
|
Before / After Photos Taken?
|
|
Local Anesthesia Volume
|
Complications:
|
|
Initials of Injector:
|
|
