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u�� �r�N� <br />F'R®GEDUFZE �EC�R® <br />�.a,,a.»�,�ooua� <br />Name: .zaz9a,:3��wn.� <br />Date: <br />Time: Procedure start: <br />Procedure end: <br />Pre -Op Checklist: Allergies: <br />Informed Consent Client History <br />Pre -Photographs No change in medical status <br />No prior fever blisters Physician's release obtained <br />If fever blisters: took Acyclovir Rx <br />Skin Preparation; Alcohol Cetaphil <br />Type of Procedure: Eyeliner Smudgy Eyeliner <br />Brows Lipliner <br />FuII lip color Wrinkle treatment (dry needles) <br />Corrective Areola <br />Scar Camouflage <br />Scar Description: Size: Color: Age: <br />_Smooth _Irregular _Straight ._Curved _Flat _Raised _Indented <br />Remarkable features: <br />Pigments; Name: Lot �: <br />Exp. Date: Formula: <br />Anesthesia; Name: Time: <br />Flame: Time: <br />Dental block per "Doctor's Name": <br />Pain Tolerance: High Medium Low <br />Procedure Tolerance. High Medium Low <br />Technique; Coil Rotary Manual <br />Name of pevice: <br />Needle Description: Shader _Round _Flat _Magnum Slope Dixon Technique <br />_Sterile Needles Used <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 Wates: <br />JC;V�A'co��2.G'G1 : `,l�c1Rm � Clop <br />ion ��eedin� �c,st NoRm�. <br />k�l��p�, ; Oily �` Nna,n�ti,Q C� ��� �_"� <br />���- ��� 30 ���� 31-�,0 �� u� - 50 <br />done 1, <br />s�l�hll,t� f ` �I one. <br />�`� s I�� <br />pp � �� _� <br />�hi G{C �...�) N o R vv� �,1, �ar�a � 1 V1. <br />51 — Go �� Gc� u� �,� <br />t�v�lf, : I�GA)F.G1 C1r Yl. � �F#QS ()r Cn l(`, l 1 �{-ik-21r'r t�/-i VV1C'.R.�i(7 Y� �K� !'�C�GY� � i <br />