First Name
*
Last Name
*
Email
*
example@example.com
Date
*
/
Month
/
Day
Year
Date
Area(s) to be treated
*
Photos Taken
*
Yes
No
Topical Anesthetic Type used
*
Treatment #
*
Tip Size
*
TOTAL SHOT COUNT
*
Post-treatment skincare applied:
Product name
*
Provider Name
Provider Signature
*
Date
*
/
Month
/
Day
Year
Date
Preview PDF
Submit
Pretreatment Record
*
Area Treated
M1/M2 or Custom
Dela Y
Power (w)
Time (ms)
Depth (mm)
# Passes
Shot Count
1
2
3
4
5
6
Should be Empty: