Mesotherapy Consent Form

I voluntarily consent to undergo Mesotherapy treatments from Celia Aesthetic Clinic.

I understand that Mesotherapy can be used for many reasons and I want to have treatment for the following:

Reduction of localized fat of

Cellulite Reduction

Mesoglow or skin rejuvenation of

I hereby consent to the Mesotherapy treatment of which I understand that more than one (1) treatment will be required. I understand that the treatment requires many small injections around the area (s) to be treated. I also understand that the administration of numbing cream may be used if deemed necessary.

I understand that the benefits of Mesotherapy may vary, but may include: a possible decrease in cellulite, a possible increase of skin tone, or a possible decrease of wrinkles.

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

• Bruising of the skin is very possible.

• Skin discomfort during the injection.

• Lightening or darkening of the skin (transient or permanent)

• Itching and bruising lasting 20 minutes to a few hours.

• Scarring of the skin in exceedingly rare instances.

• Skin infection is a possibility anytime a surgical procedure is performed

• Nausea, dizziness, and possible allergies to Hyaluronidase enzymes may occur.

By my below signature, I acknowledge that I have been informed about the above medications and give consent to its use in my treatment. .

I understand that this treatment is strictly for cosmetic purposes and will not be covered by insurance.

I also understand that I am responsible for all costs payable at the time of service.

Patient Name:

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Doctor Name

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