PHOTO TREATMENT RECORD
tr309
CLIENT SECTION
Client Name
*
First Name
Last Name
Contraindications
*
Recent sunburn
History of seizure
Lupus, Epilepsy, Skin cancer, Eczema, Psoriasis, Active infection
Fake tan
Photosensitizing Medication
History of Herpes Simplex/ Cold Sores (antiviral medication for 7 days by own physician)
Ocular disease
Pregnancy
None
Treatment Consent
*
I fully understand the treatment expectations. The above contraindications do not apply to me. I understand that possible side effects include Burning, Blistering, Redness, Hyperpigmentation, Photosensitivity. Aesthetic treatment results may vary from person to person. Pre and post treatment instructions must be followed for the intended cosmetic results, failure to disclose contraindications and not following instructions may result in the above possible side effects and compromised cosmetic results.
Client Signature
*
Understood and Accepted
OFFICIAL USE ONLY
Fitzpatrick Skin Type
*
Please Select
I
II
III
IV
V
VI
Skin Condition
*
Acne
Pigmentation
PIH
Redness/Rosacea/Telangiectasia
Visible Veins
Wrinkles/Lines
Elasticity/Volume Loss
Enlarged Pores
Acne scarring
Pore Congestion
Dark Spots
Angioma
Treatment Interval
*
Please Select
N/A
1 Week
2 Weeks
3 Weeks
4 Weeks
5 Weeks
Over 5 Weeks
Treatment Time
*
Hour Minutes
to
until
Hour Minutes
Total 0.0
Treatment Date
*
-
Day
-
Month
Year
Parameters
*
Wavelength/Band(nm)
Fluence (J/cm²)
Pulse Duration/Width (ms)
Pulse Delay (ms)
?
Number of Pulses
Shot Count
Pain Scale
Pass 1
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 2
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 3
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 4
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 5
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 6
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 7
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pass 8
DPL 550-650
430
460
530
560
590
640
750
800
0
1
2
3
4
5
6
7
8
9
10
Pre-Treatment Care
*
Retinol
Tretinone
Niacinamide
Vitamin C derivatives
AHA
BHA 10%
BHA 20%
BHA 30%
ENZY
Hydroquinone
Others
Pre-Treatment Care Notes
Post-Treatment Care
*
Retinol
Tretinone
Niacinamide
Vitamin C derivatives
AHA
BHA 10%
BHA 20%
BHA 30%
ENZY
Hydroquinone
Others
Post-Treatment Care Notes
Side Effects
*
Erythema
Blistering
Swollen
Hyperpigmentation
Pain/soreness
Herpes Simplex/Cold sore
Others
None
Other side effects
Clinician
*
First Name
Last Name
CLID
*
Clinician Email
*
example@example.com
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