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CONSULT
|
|
|
CONSULTATION
|
|
|
Notes/Recommendations
|
|
|
Consult Provider
|
|
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TREATMENT
|
|
|
TREATMENT
|
|
|
# of sessions
|
# of vials
|
|
LOT#
|
Exp. Date
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|
Area(s) Treated
• • •
|
|
|
Notes:
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|
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Tolerated Tx Well?
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No Adverse Reactions Noted Upon D/C?
|
|
Verbal/Written Post Instructions Given?
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Pt Verbalized Understanding of all Post Instructions?
|
|
Follow Up
|
|
|
Treatment Provider
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