Exilis Face Treatment Sheet - Female
First Name
Last Name
Email
Patient email on file
Date of treatment
/
Month
/
Day
Year
Date
Treatment #
1
2
3
4
5
6
7
8
Location of grounding pad
Upper Back
Other (Type Below)
Other
Photos Taken
Yes
No
Notes
Treatment Area (s): Mark area(s) below
Draw on Image
Treatment Setting
Treatment Setting
Treatment Setting
Treatment Setting
Treatment Setting
Treatment Area
MaxPower/MinPower
Duty Factor %
Total Tx Time (Min) (Per 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
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