Laser Patch Test Results Form
Record and track outcomes for laser patch test procedures.
Patient/Client Identifier
*
Date of Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Practitioner/Operator Name
*
Laser/Device Name or Model
*
Test Patch Location
*
Please Select
Forearm
Upper Arm
Thigh
Back
Face
Other
Treatment Settings Used
*
Observed Skin Response/Results
*
Reaction Severity Rating
*
1
2
3
4
5
Recommended Next Step
*
Proceed with treatment
Repeat patch test
Consult physician
Discontinue
Other
Notes or Follow-Up Instructions
Submit
Should be Empty: