EmSculpt Treatment Log
First Name
*
Last Name
*
Email
*
Patient email on file
Date
*
/
Month
/
Day
Year
Date
Photos Taken
*
Yes
No
Treatment area(s) - describe or mark on diagram:
Treatment Areas
Describe or mark on diagramt
Draw on Image
*
Type a question
*
Date
Protocol
Treatment Time
Maximum Intensity Reached
Circumference Measurement
Comments
1
2
3
4
5
6
Provider Name
*
Provider Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
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