Submental Treatment Sheet
First Name
*
Last Name
*
Email
*
Patient email on file
Date
*
/
Month
/
Day
Year
Date
BMI
*
Weight
*
Age
*
Pre TX images taken
*
Yes
No
TX #
*
# of PACs used
*
Type a question
*
TX AREA
STARTING ENERGY (W/cm²)
Zone Score Post Build
Energy Adjustment/ZoneScore 2min
Energy Adjustment/Zone Score 2 min
Energy Adjustment/Zone Score 2 Min
Energy Adjustment/Zone Score 2 Min
Energy Adjustment/Zone Score 2 Min
1
2
3
Treatment Notes
*
Draw on Image
*
Provider Name
*
Provider Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
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