Mesotherapy

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PATIENT CONSENT

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of mesotherapy. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment. It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process.

Mesotherapy is a technique that uses customised mixtures of vitamins, herbal extracts, enzymes, amino acids, and/or other medications placed with fine needles, just millimeters into the middle layer of the skin.

Mesotherapy is used for cosmetic purposes such as skin rejuvenation as well as fat and cellulite removal. Uses of mesotherapy include cellulite reduction, removal of fat in multiple body areas, body recontouring, skin rejuvenation and tightening, treatment of treat fine lines and wrinkles and areas of hyperpigmentation. Many different formulas exist for the substances injected during mesotherapy; your practitioner will discuss the options that are available to you. Any formulas that contain prescription only medications your practitioner will organise a prescription consultation with a medical doctor of prescribing nurse. If your practitioner is a prescribing medic then this would not be required. It is important that you complete all the below questions and inform your practitioner of any allergies and medical problems you have.

I am aware that results vary between clients and results are dependent on many individual factors. The time of onset for visible results and the duration of results again varies between clients and depends on other factors such as the aim of treatment. I am aware that there is no guarantee that I will achieve desired results and that multiple treatment courses may be needed to achieve or maintain desired results. I am also aware that this treatment is cosmetic and is not designed to cure any medical condition or act as a substitute for medical care. For any medical conditions I have seen my doctor for diagnosis and management. I understand the treatment is most successful when combined with diet and exercise. Results of fat loss will only be maintained so long as you continue to not gain further body fat after the treatment course. I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.

RISKS AND SIDE EFFECTS: As with any procedure there are potential risks and complications associated. You must be aware of all the following risks before proceeding and fully discuss any questions with your practitioner. Common risks include some mild pain or discomfort, the skin may appear red or swollen afterwards, this should settle normally within 48 hours. You may experience some minor bleeding or bruising that will resolve naturally. You may experience some mild irritation at the treatment site. Sometimes people can faint or feel faint with needles, you must tell your practitioner as soon as possible if you feel unwell during the treatment. Uncommon risks include skin infection (cellulitis), reactivation of cold sores (herpes simplex infection), temporary changes in skin pigmentation to lighter or darker which should usually resolve within 6 months. Temporary bumps or unevenness at the treatment site. Rare risks include permanent skin pigmentation changes, permanent skin scarring, allergic reaction to a constituent of the mesotherapy formula injected. Allergic reaction usually presents as swelling and red rash however in extremely rare cases clients can develop an anaphylactic reaction. This is life threatening and would require emergency medical attention.

I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:

- the aims/motivations for having the procedure and the desired outcome

- the risks inherent in the procedure

- the risks inherent in refusing the procedure

- the risks specific to me

- the expected benefits of the treatment

- the potential disadvantages of the treatment

- alternative procedures and their pros and cons

- including the option of no treatment at all

- any uncertainties about and the likelihood of success of the procedure

- any follow-up treatment that may be required

CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records. I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully for me to make an informed decision. I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.

Do you understand the information you have been provided? *

Yes

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Do you feel sufficient information has been provided to you, to enable you to consent? *

Yes

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Has your consent been freely given? *

Yes

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Do you have any medical conditions? *

Yes

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Are you pregnant or breastfeeding? *

Yes

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Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy myasthenia gravis, or Lambert-Eaton syndrome)? *

Yes

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Do you have an autoimmune disease? *

Yes

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Do you have any skin conditions? *

Yes

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Do you have any known allergies or have ever had anaphylaxis? *

Yes

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Do you have any active infection at the intended site of procedure? *

Yes

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Are you taking antibiotics or other prescription medications? *

Yes

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Is there any other Medical and/or Social History that we should know? If so, please provide full detail here. *

Yes

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What are your aims/motivations for having the procedure and the desired outcome? Please provide full details here. *

Yes

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Have you had this or a similar treatment before? If so, did you experience any problems? Please provide full details here. *

Yes

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Do you have any concerns? If so, please provide full details here. *

Yes

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Is there anything else we should know? Please provide full details here. *

Yes

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I will retain this information throughout the course of my treatment and refer to it as required. *

Yes

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I agree to allow my treatment photos to be used for promotional and marketing purposes. *

Yes

I accept the updated terms and conditions of Faces Consent, which include receiving aftercare guidance, treatment-related recommendations, by communication channels. I understand that I can opt out at any time. *

Yes

Notes

Before Treatment photos

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