Vi Peel Treatment Log
First Name
*
Last Name
*
Email
*
Patient email on file
Date
*
/
Month
/
Day
Year
Date
Treatment #
*
Peel Type
*
Lot #
*
Exp Date
*
/
Month
/
Day
Year
Date
Note
*
Provider Name
*
Provider Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
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