MESOTHERAPY CONSENT FORM

I, , voluntarily consent to undergo Mesotherapy treatments provided by . 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 topical anesthesia may be used if deemed necessary.

I understand that the benefits of Mesotherapy will vary but may include a decrease in cellulite, an increase in skin tone, a decrease in wrinkles, and may eliminate or decrease pain.

I understand that there are some risks with any procedure. Complications of Mesotherapy are rare and usually self-limited, but include the following:

Discomfort: Medication is injected with tiny needles just below the skin. There may be brief minimal discomfort from the injections.
Bruising: Occasionally, the needle may puncture a small blood vessel, resulting in a bruise.
Swelling and Redness: This may result following the procedure as the medication begins to work.
Scarring: Scarring may result from multiple injections, but this is very unlikely.
Allergic Reaction: Although exceedingly rare, the possibility exists of an allergic reaction to the injection of Mesotherapy medications.
Infection: Since Mesotherapy treatment involves injections, there is a theoretical risk of developing an infection at the injection site. This is also exceedingly rare.
Discoloration: Transient or permanent skin pigmentation changes can sometimes occur at injection sites.

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

I have met with the Doctor who is overseeing my treatment and have discussed all treatment options available to me.
The Doctor has informed me, and I understand, that the result of Mesotherapy is individual and varies depending on the area treated, skin type, the injection technique, and the use of different products. Therefore, no guarantee can be made as to the results of my treatment.
I understand that the effects of the treatment with these products can last, on average, 3 or more months with complete treatment, but that in some cases the duration of the effects can be shorter or longer. Touch-up and follow-up treatments may be needed to sustain the desired degree of my treatment.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
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.

Consent

I, undersigned, have read and understand the information contained within this consent form. My signature indicates that I have read and understand the information in the consent. I hereby release and my provider from all liability associated with this procedure. Furthermore, my signature below indicates my consent to the treatment described and my agreement to comply with the requirements placed on me by this consent form.

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.