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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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Consent
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Before Photos Taken?
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ETOH Prep?
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Treatment #
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Area treated
• • •
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Cartridge Type
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Treatment Serum
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Procedure Depth
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Forehead (0.25-1.0mm)
• • •
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Nose (0.25-0.75mm)
• • •
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Cheek (1.00-2.5mm)
• • •
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Chin (0.75-1.5mm)
• • •
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Facial Scars (up to 1.5mm)
• • •
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Around the Orbital Rim (0.25-0.5mm)
• • •
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Tolerated Tx Well?
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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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