Exilis Face Treatment - Male
First Name
*
Last Name
*
Email
*
Patient email on file
Date of treatment
*
/
Month
/
Day
Year
Patient email on file
Treatment #
*
1
2
3
4
5
6
Location of grounding pad
*
Upper Back
Other
Other
*
Notes
*
Treatment Area (s): Mark area(s) below
*
Draw on Image
*
Rate patient discomfort during treatment
*
NON E
MILD
MODE RATE
SEVERE
Rate erytheme immediately post treatment
*
NON E
MILD
MODE RATE
SEVERE
Rate edema immediately post
*
NON E
MILD
MODE RATE
SEVERE
Provider Name
*
Provider Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
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