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PROCEDURE RECORD <br /> Name: <br /> Date; <br /> Time: Procedure start: ------ <br /> Procedure end: <br /> Pre-op Checklist: Allergies: <br /> -Informed Consent No <br /> History <br /> -Pre-Photographs -No change in medical status <br /> -No prior fever blisters -Physician's release obtained <br /> Skin Preparation: -If fever blisters: took Acyclovir Rx <br /> Alcohol <br /> Type <br /> Type of Procedure: Eyeliner -Smudgy Eyeliner <br /> =:JBrows -Lipliner <br /> -Full lip color- <br /> Pigments: Name: <br /> Exp. Date: Lot #: <br /> Formula: <br /> Anesthesia: Name: Time: <br /> couc C, SiCLl.1 �4 1 c -Af iCGlA <br /> Pain Tolerance: High Medium Low <br /> Procedure Tolerance: High Medium Low <br /> Technique: Rotary Manual <br /> Name of Device: <br /> Needle Description: Shader-Round-Flat <br /> Post-Op Care: -Healquick-Retain Ointment_Aquaphor-Petrolatum <br /> Other: <br /> -Aftercare instructions given (including emergency contact numbers) <br /> -Post-procedure photographs taken <br /> Procedure Notes: <br /> Price: <br /> Method of Payment: -Cash -Check -Visa- -MasterCard <br /> Reviewed By: <br /> Sv. 0 40 4 50 51 - 60 G0 U <br /> r 1. H L t Uf oAq NoQw)nk , dQq NoQmC.'o 1-�_ <br /> J lzlnc�,L N <br />