Exilis Femme Treatment Sheet
First Name
*
Last Name
*
Email
*
Patient email on file
Date of treatment
*
/
Month
/
Day
Year
Date
Treatment #
*
1
2
3
4
5
6
Location of grounding pad
*
Upper Back
Other (Type Below)
Other
*
Photos Taken
*
Yes
No
Treatment Area (s): Mark area(s) below
*
Treatment Setting
*
INTERNAL
INTROITUS
R LABIS
L LABIS
MONS PUBIS
PERINEUM
Treatment Area
Patient Response
*
NONE
MILD
MODERATE
SEVERE
Rate patient discomfort during treatment
Rate erytheme immediately post treatment
Rate edema immediately post treatment
Treatment Note:
*
Provider Name
Provider Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: