Exilis Face Treatment - Male
First Name
Last Name
Email
Patient email on file
Date of treatment
/
Month
/
Day
Year
Patient email on file
Treatment #
1
2
3
4
5
6
Location of grounding pad
Upper Back
Other
Other
Notes
Treatment Area (s): Mark area(s) below
Draw on Image
Rate patient discomfort during treatment
NON E
MILD
MODE RATE
SEVERE
Rate erytheme immediately post treatment
NON E
MILD
MODE RATE
SEVERE
Rate edema immediately post
NON E
MILD
MODE RATE
SEVERE
Provider Name
Provider Signature
Date
-
Month
-
Day
Year
Date
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