Fat Dissolving injections

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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 Aqualyx fat dissolving injections (Intralipotherapy). 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.

Aqualyx is a fat dissolving injection product. Fat dissolving injections aim to destroy fat cells by damaging the fat cells plasma membrane, allowing the fatty acids inside the cell to be broken down and be naturally removed by the lymphatic system. In simple terms they liquify fat and allow the body to remove it naturally. The fat dissolving product is injected directly into the subcutaneous fat with either a needle or cannula. Your practitioner may often add lidocaine to the Aqualyx product to help with pain control during injections. It is important to use fat dissolving injections in conjunction with a healthy diet and regular physical exercise.

Fat dissolving injections are not a substitute for lifestyle measures however they are useful at helping to remove stubborn localised fatty deposits that have been difficult to lose with diet and exercise measures alone.

Aqualyx fat dissolving injections can be used in the following body areas, abdomen, flanks, upper arms, bra area, thighs, body cellulite, jowls and double chin. Other body areas can also be treated that have not been listed. The number of treatments required depends on the area of treatment as well as the amount of fat to be dissolved in that area.

Generally, 2-4 sessions are needed at 4-6-week intervals. Initial results can be expected to be seen from 3-4 weeks. I also understand that results vary between clients and there is no guarantee that I will achieve the results I desire. The removal of fat cells is permanent, and results will be permanent if you do not gain further weight in between or after treatment sessions. 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: I understand that there are risks and complications associated with Aqualyx fat dissolving injections and that I have read and understood the possible complications before proceeding with treatment. I have fully discussed anything required with my practitioner. Common side effects include pain or burning sensation during the injections. Following injections itching, swelling and redness of the treated areas is likely soon after treatment. These effects should normally improve within 24 hours after the initial injections and should be greatly improved after 5 days. Bruising may occur after treatment which may take up to 2 weeks to resolve. The treated area may feel tender for up to 2-3 weeks after treatment. Sometimes people can faint or feel faint with injections, you must tell your practitioner as soon as possible if you feel unwell during the treatment. Uncommonly you may experience transient nodules afterwards in the treatment area, these can feel lumpy but will resolve naturally in most cases within 1 month. Rare complications include skin infection after treatment (cellulitis), allergic reaction or anaphylaxis to the product, nerve injury resulting in tingling and numbness in the affected area, skin pigmentation changes which may be permanent, permanent nodules and skin necrosis. 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 in order 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

Before Treatment Photos

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Notes

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