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 agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation, and Dubai Health Authority Policies."

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.

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