INFORMED CONSENT FOR LIPOLYSIS (FAT MELTING INJECTIONS / LIPO MESOTHERAPY)


Patient�s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Procedure Time:
Doctor Name:

I voluntarily consent to undergo Lipolysis or Lipo Mesotherapy treatments provided by and its licensed doctors, nurses, physician associates, or qualified staff members employed by the practice. I understand that Lipolysis can be used for many reasons and I want to have treatment for the following: Reduction of localized fat of I hereby consent to the Lipolysis 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 necessary. I also understand that there are some risks with any procedure. The following is a list of possible risks associated with Lipolysis:

  • 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 the Deoxycholic acid may occur.
  • Skin infection is a possibility any time a surgical procedure is done.

By my signature, I acknowledge that I have been informed about the above medications and give consent to their use in my treatment. I understand that the practice of medicine is not an exact science; therefore, no guarantee can be made as to the results of my treatments. I understand that this treatment is strictly for cosmetic purposes and will not be covered by insurance. I understand that I am responsible for all costs payable at the time of service. By my signature, I certify that I have thoroughly read and understand the contents of this form and that the disclosures listed above were made to me.

Lipolysis Post-Treatment Instructions

  • Immediately after the treatment, the most commonly reported side-effects were temporary redness, bruising, and swelling at the injection site. These effects typically resolve within 5 to 10 days. Cold or ice compresses may be used immediately after treatment to reduce swelling.
  • Apply 1% Hydrocortisone cream or Benadryl spray or gel on treated areas to reduce itching or redness.
  • It is normal to feel dryness of the mouth after the procedure and have dark yellowish urine. Please try to double your water intake. Increased water intake is a must for the patient's weeks after the procedure.
  • To minimize bruising, avoid Aspirin, Anti-inflammatory drugs, Gingko biloba, Garlic, Flaxseed Oil, Vitamin E, Alcohol, spicy food, salty food, and cigarettes 48 hours to 1 week after your treatment.
  • It is normal to feel �firmness� in the injection site on the first day after treatment. In some cases, a lumpy formation can be felt on the injected area. If necessary, massage the area gently 2-3 times a day for up to 72 hours.
  • Do not exercise for 24 hours after treatment. Avoid strenuous exercises, sunbathing, or tanning.
  • Apply sunblock and protect your skin from sunlight.
  • For treatment of neck areas, sleep with your head elevated (3-4 pillows) and wear some compression under the chin (scarf or headband).
  • Call us immediately if you start experiencing these symptoms or develop any persistent side effects.

IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:

  • THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
  • THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
  • THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take full responsibility for my decision in this consent.


Patient Name and Signature:

Doctor Name :
Signature


Therapist/Witness:
Signature and Stamp:
Date

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form


Patient Name and Signature: