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Request to ADD More Treatments Form
Today's Date
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+
Your Name
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Clinic
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Albuquerque
Amarillo
Corpus Christi
El Paso
Lubbock
Midland
Client Name
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Procedure
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Laser Hair Removal
Zeltiq
MicroNeedling
Ultrasonic Facials
Other
Procedure Area
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🛈
# Tx Received
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% Improvement
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10%
20%
30%
40%
50%
60%
70%
80%
90%
95-100%
2nd Procedure
Laser Hair Removal
Zeltiq
MicroNeedling
Ultrasonic Facials
Other
2nd Procedure Area (If any)
🛈
# Tx Received
% Improvement
10%
20%
30%
40%
50%
60%
70%
80%
90%
95-100%
Notes
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