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I voluntarily consent to undergo Mesotherapy treatments provided by the practitioner, associates, or qualified staff members employed by the practice.

I understand that Mesotherapy can be used for many reasons and I want to have treatment for the following; Reduction of localized fat of the named below.

I hereby consent to the Mesotherapy treatment of which I understand that more than one (1) treatment is required.

I understand that the treatment requires many small injections around the area (s) to be treated.

I understand that the administration of numbing cream may be used if deemed needed.

I understand that there are some risks with any procedure. The following is the list of possible risks with Mesotherapy:

  • Bruising of the skin is very possible.
  • Skin discomfort during the injections.
  • Redness or swelling at the injection site.
  • Lightening or darkening of the skin (transient or permanent)
  • Itching and burning lasting 20 minutes to a few hours
  • Scarring of the skin is unlikely.
  • Nausea, dizziness, and possible allergies to Deoxycholic acid may occur.
  • Skin infection is a possibility any time a surgical procedure is done.

Before receiving Lipodissove Mesotherapy injections: Tell your practitioner about all of your medical conditions, including if you:

Have an infection in the treatment area

Have had or plan to have surgery on the face, neck, or chin

Have had cosmetic treatments on the face, neck, or chin

Have had or have medical conditions in or near the neck area

Have trouble swallowing Have bleeding problems or are taking blood thinners

Are pregnant or plan to become pregnant. It is not known if Fat-dissolving Treatment will harm an unborn baby.

Are breastfeeding or plan to breastfeed. It is unknown if Fat-dissolving Treatment passes into your breast milk.

Tell your practitioner about all medications you currently take, including prescriptions and over-the-counter medicines, vitamins, and herbal supplements. Tell your practitioner if you take a medicine that prevents the clotting of blood (antiplatelet or anticoagulant medications such as aspirin, non-steroidal anti-inflammatory medications).

I have read this informed consent and certify that I understand its contents in full. I have been informed that I must not apply any kind of cosmetics onto the treated area within the first twelve hours following the treatment with Lipodissolve Mesotherapy and that immediate exposure to heat sources during the following days are to be avoided (e.g. sunlight, UV-radiation, sauna). I am aware of the fact that after therapy with Lipodissolve Mesotherapy treatments using a laser, cryolipolysis or radio-frequency-therapy must not be administered. Furthermore, I should abstain from particularly demanding physical exercise for seven days.

I have been given a copy of this consent form. My consent and authorisation for this procedure are strictly voluntary.

By signing this informed consent form, I grant authority to my practitioner to perform intralipotherapy using Lipodissove Mesotherapy and to administer an additional ultrasound treatment as may be deemed necessary or advisable in the diagnosis and treatment of my condition.

The nature and purpose of this procedure, with possible alternative methods of treatment as well as complications, have been fully explained to my satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have had enough time to consider the information from my practitioner and feel that I am sufficiently advised to consent to this procedure.

I hereby give my consent to this procedure and have been asked to sign this form after my discussion with the practitioner.

 

Today's Date: September 7, 2024

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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
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 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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