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LAP BAND ADJUSTMENT
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Lap Band Adjusted
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Fluid in Band - Current
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Fluid Removed
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New Total Fluid in Lap Band
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Close to sweet spot?
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Slipped?
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Did they feel restriction from last fill?
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Radiographic studies
• • •
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Notes
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PELLET INSERTION
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Male Pellet Insertion
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Date of last insertions
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Insertion Procedure
• • •
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Post procedure instructions given
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Female Pellet Insertion
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Date of last insertions
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Insertion Procedure
• • •
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Post procedure instructions given
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STEM CELL PROCEDURES
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Stem Cells
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Allergy History
• • •
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Stem Cell Consent
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Stem Cell Consent
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Stem Cell Infusion
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IV location
• • •
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IV Gauge
• • •
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IV number of attempts to place catheter
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IV complications
• • •
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Pre-infusion medication
• • •
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Stem Cell Dosage weight based
• • •
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Treatment result
• • •
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Severe reaction
• • •
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Stem Cell Injection
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Stem cell injection site
• • •
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Stem Cell injection dosage
• • •
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Comments
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Platelet Rich Plasma and/or Exosomes
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Platelet Rich Plasma
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Consent for PRP/Exosomes reviewed and signed
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PRP injection
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PRP Aesthetic
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Exosome Injection
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Exosome Aesthetic
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Exosome Procedure Aesthetic
• • •
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Other Office Surgery
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Surgical Procedure
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IV/IM NUTRITION
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IM Nutrition/Treatment
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Consent for IM/IV nutrition
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IM Nutrition
• • •
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IV Nutrition
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IV Nutrition/supplementation
• • •
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Add on nutritionals
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Add on IV Nutritionals
• • •
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Add on comments
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