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CONSULT
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CONSULTATION
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Notes/Recommendations
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Consult Provider
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TREATMENT
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TREATMENT
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Syringe #1
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Product Injected?
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Area(s) Treated
• • •
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Lot #
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Expiration Date
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Notes:
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Syringe #2
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|
|
Product Injected?
|
Area(s) Treated
• • •
|
|
Lot #
|
Expiration Date
|
|
Notes:
|
|
|
Syringe #3
|
|
|
Product Injected?
|
Area(s) Treated
• • •
|
|
Lot #
|
Expiration Date
|
|
Notes:
|
|
|
Syringe #4
|
|
|
Product Injected?
|
Area(s) Treated
• • •
|
|
Lot #
|
Expiration Date
|
|
Notes:
|
|
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|
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Follow Up
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Treatment Provider
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