Treatment Consultation Form - PatientPop › assets › docs › 11588.pdf · Treatment...
1
Transcript of Treatment Consultation Form - PatientPop › assets › docs › 11588.pdf · Treatment...
-
Treatment Consultation FormPatient Name: Date:
Gender: Weight: Age: BMI:
What are the patient’s areas of concern?
How did he/she hear about SculpSure?
Has your patient tried other fat reduction methods? If yes, please list:
Is your patient preparing for any special events?
Notes:
921-7026-015R1FOR OFFICE USE ONLY
Front
Treatment Plan
Back
Treatment Price: Discount: Total:
Treatment 1:Treatment 2:Treatment 3: