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This form is used to inform patients of the purpose of Mesolipotherapy, as well as its potential risk and indications. Please read through this form in its entirety before signing at the bottom. If you have any questions or concerns about this form, please ask a Pure Cosmetics staff member before signing.

About Mesolipotherapy

Mesotherapy is a method of introducing medications into the body through microinjections of the mesoderm of the skin.  It originated in 1952 in Paris, France, by Michel Pistor, MD..  Jacque Le Coz, MD and Dr. Pistor worked to improve the methodology, and the Academy of French Medicine recognized it as a “standard of care” along with other traditional medicine in 1986.  It is used for a large variety of illnesses, including tendonitis, eczema, scars, and sports injuries, in addition to cellulite stages 1-3, treatment of alopecia and hair loss, and facial rejuvenation treatments.  The depth of treatment is 0.5mm-6mm deep (called Nappage technique).  When the depth is 6-12mm (the Point Per Point technique) and reserve fat is treated, it is called Lipotherapy. Combining meso- and lipo-therapy, we can use deoxycholate and phosphatidyl choline to permanently reduce the amount of fat to a treated area, and tighten the skin.

Possible Risks and Side Effects

Potential risks and side effects can include, but are not limited to:

  • Infection
  • Bleeding
  • Swelling
  • Bruising
  • Pain
  • Hyperpigmentation
  • Nodules
  • Redness
  • Over correction
  • Under correction
  • Skin necrosis, and
  • Delayed hypersensitivity

I have read of the possible risks and and side effects of treatment, and consent to move forward with treatment.

Guarantee of Treatment

I understand that no guarantees as to the amount of improvement can be made, and that diet and exercise can affect the outcome.  I understand that Mesotherapy and Lipotherapy have a goal of decreasing inches and permanent spot fat reduction, and that its primary goal is not to reduce weight.  I acknowledge that I have had the opportunity to discuss all questions regarding this treatment with Pure Cosmetics and that they have been answered satisfactorily.  My signature will constitute a full and final release of any legal responsibility resulting from the administration of mesotherapy and/or lipotherapy, as well as any other medical treatment that may be needed as a result thereof.  

Additional Information

To my knowledge, I am not pregnant, and not breastfeeding, and will notify Pure Cosmetics immediately if I think I have become pregnant or become pregnant during the course of treatments.

I understand that adjunctive procedures, such as microdermabrasion, use of sunblock products, prescription skin care regimens, and facials performed by experienced Estheticians may enhance the outcome, health and appearance of the skin treated with Mesolipotherapy.

I understand and consent to the taking of photos of my body and face before, during and after the course of treatment(s) for medical record keeping.

First Patient's Name

First Name*

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please select the desired area(s) to be treated: *
Chin/Jowls
Upper Arms
Breasts (Male)
Back/Bra Fat
Flanks/Love Handles
Upper Abdomen
Lower Abdomen
Front Thigh
Outer Thighs
Back Thigh
Inner Thighs
Click to customize question*
No
Yes
Please select any of the following that you have been diagnosed or treated with/for:
Autoimmune disease (other than Thyroid andd Rheumatoid Arthritis)
Any bleeding disorders, or medications such as Coumadin or Plavix
Kidney Failure
Liver Failure
Chemotherapy
Steroids
Currently pregnant/breast-feeding
Soy Allergy
Latex Allergy
Parent or Guardian's Signature*
Electronic Signature Consent*
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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