Chemical Peel Progress Notes "*" indicates required fields CHEMICAL PEEL PROGRESS NOTESTo be completed by medical professJonalPatient Name* First DOB* MM slash DD slash YYYY M/F*- Select One -MailFemailSKIN ASSESSMENTFitzpatriok skin type (circle)* I II III IV V VI Check all that apply* Oily Acne Melasma Dry Acne Scarring Hyperplgmentation Sensitive Excoriations Hypopigmentation Sun damage (circie): Mild Moderate Severe Sun damage (circie): Mild Moderate Severe AllergiesCONCOMlNANT MEDICATIONS/PRODllCTSMedications*MedicationsSkin Care Products Add RemovePEEL TREATMENT (check)PEEL TREATMENT (check)* ILLUMINIZE PEEL® VITALIZE PEEL® REJUVENIZE PEEL™ Treatment #OfTreated Area* Face Neck Chest Step 1 :Prepping SolutionLot #Exp.Date MM slash DD slash YYYY Step 2 :Peelng SolutionLot #Exp.Date MM slash DD slash YYYY Number of Passes 1 2 3 Step 3 : For Vitalize Peel/Rejuvenize Peel ONLYVitalize Retinol Solution Vitalize Retinol Solution Lot #Exp.Date MM slash DD slash YYYY Rejuvenize Retinol Solution Rejuvenize Retinol Solution Lot #Exp.Date MM slash DD slash YYYY N/A N/A Step 4 :Sun Protection Sun Protection SKIN REACTIONErythema None Mild Moderate Severe Areas affectedBurning None Mild Moderate Severe Areas affectedFrosting None Level I Level II Level III Areas affectedEdema None Mild Moderate Severe Areas affectedOther (Please Iist)Provider Full NameDate MM slash DD slash YYYY
