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BBL Consent
|
|
|
BBL treatment counseled?
|
Concerns
• • •
|
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No Contraindications are present
|
Recent antibiotic or chem peels?
|
|
Pt report suspicious lesion?
|
Additional Comments
|
|
|
|
|
Fitzpatrick Skin Type
• • •
|
|
|
Skin Baseline Exam
• • •
|
Skin Baseline Exam: Comment
|
|
Suspicious lesions?
|
Suspicious lesion comment
|
|
Pre Treatment Photo 1
|
Pre Treatment Photo 2
|
|
Pre Treatment Photo 3
|
Pre Treatment Photo 4
|
|
|
|
|
Laser Device Used
• • •
|
|
|
Initial Tx Test spot?
|
|
|
Area Treated 1
• • •
|
Wavelength 1
• • •
|
|
|
Laser Energy Used 1
• • •
|
|
|
Additional Notes
|
|
|
|
|
Area Treated 2
• • •
|
Wavelength 2
• • •
|
|
|
Laser Energy Used 2
• • •
|
|
|
Additonal Notes
|
|
|
|
|
Area Treated 3
• • •
|
Wavelength 3
• • •
|
|
|
Laser Energy Used 3
• • •
|
|
|
Additional Notes
|
|
|
|
|
Area Treated 4
• • •
|
Wavelength 4
• • •
|
|
|
Laser Energy Used 4
• • •
|
|
|
Additional Notes
|
|
Additional Treatment Notes
|
|
|
|
|
|
Appropriate Treatment Response?
|
Treatment response comment
|
|
Complication?
|
Complications comment
|
|
Post Laser Instructions Given
|
Follow Up
|
|
Laser done by
• • •
|
|
