Follow-Up & Outcome Assessment

A structured follow-up to assess healing, satisfaction, and the response to treatment. Honest feedback helps the provider refine your treatment plan.

Follow-Up Header

Patient name:

Original treatment performed:

Original treatment date:

Follow-up week #:

Follow-up date:

Follow-up mode:

In-clinic visit

Video consultation

Photos sent by patient

Phone call

Photo Review

Pre-treatment photo on file

Current follow-up photo taken

Side-by-side comparison performed

Archive ID:

Patient Satisfaction

Overall satisfaction (0–10):

Pain during procedure (retrospective, 0–10):

Pain post-procedure (days):

Downtime experienced (days):

Improvement Assessment

Rate improvement on a scale of 1 (no change) to 5 (excellent improvement) for each concern area.

Concern area 1 — rating (1–5):

Concern area 1 — notes:

Concern area 2 — rating (1–5):

Concern area 2 — notes:

Concern area 3 — rating (1–5):

Concern area 3 — notes:

Concern area 4 — rating (1–5):

Concern area 4 — notes:

Adverse Events

Adverse events reported — select all that apply:

Bruising

Swelling

Asymmetry

Hyperpigmentation

Hypopigmentation

Nodules

Lumps / firmness

Numbness / paresthesia

Persistent redness

Infection

Cold sore reactivation

Other adverse events — describe:

Severity:

Mild

Moderate

Severe

Resolved

Ongoing

Treatment provided for adverse events:

Areas of Concern Voiced by Patient

In the patient‘s own words — concerns or observations:

Provider Clinical Assessment

Provider's assessment of healing, response, and outcome:

Touch-Up Required

No touch-up required

Yes — touch-up recommended

Touch-up plan — area, units / ml, pricing:

Complimentary touch-up

Paid touch-up

Touch-up appointment date:

Next Maintenance Appointment

Recommended next maintenance date:

Treatment to be performed:

Rationale for next maintenance:

Patient Education Reinforcement

Sun protection reviewed

Daily SPF reinforced

Skincare adherence reviewed

Questions answered during this follow-up:

Sign-off

Provider signature (printed name):

I, the patient, acknowledge this follow-up has been completed

Thank you for completing this follow-up. Your feedback helps us continue to refine your treatment plan and improve future outcomes.