SculpSure Treatment Sheet

SculpSure Treatment Record
First Name*
Last Name*
Email*
Patient email on file
Date*

MonthDayYear
Date
Height*
Weight*
TX #*
Age*
Measurements*
Pre TX images taken*

YesNo
Number of PACs used*

Type a question*

	TX Area	Energy Build Zone Score	Energy Adjustment/Zone 2	PAC #1 Watt/Zone	PAC #2 Watt/Zone	PAC #3 Watts/Zone	PAC #4 Watts/Zone
1
2
3
4
5

Notes*
Draw on Image*
Provider Name
Provider Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: