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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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Treatment #
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Area treated
• • •
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# of layers
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Protocol
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Cleanse
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Prep/degrease
• • •
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PCA Peel Type
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Retinoid Treatment
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Correct
• • •
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Hydrate
• • •
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Protect
• • •
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Daily care product recommendations
• • •
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Verbal/Written Post Instructions Given?
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Pt Verbalized Understanding of all Post Instructions?
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Notes
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Follow Up
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Treatment Provider
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