I, ______________________________, voluntarily consent to undergo Mesotherapy treatments provided by Keiko Kalon or other certified estheticians, nurses, physician associates or qualified staff members employed by the practice.
I understand that Mesotherapy 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 Mesotherapy treatment of which I understand that more than one (1) treatment is required. I understand that the treatment may requires many small injections around the area (s) to be treated. I understand that self-administration of numbing cream may be used if deemed needed.
I understand that there are some risks with any procedure. The following is the list of possible risks with Mesotherapy Serums:
Allergic Reaction to the ingredients in the Mesotherapy serums we use at Keiko Kalon 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 after treatment. Nausea, dizziness, and possible allergic reaction to the Deoxycholic acid or other serum ingredients may occur.
By my signature, I acknowledge that I have been informed about the above medications and give consent to its use in my treatment. I know 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 the disclosures listed above were made to me
Mesotherapy Hyaluron Pen Post-Treatment Instructions
Immediately after the treatment, the most 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.
Continue taking Arnica Montana up to 7 days after each treatment to decrease bruising and inflammation.
Apply 1% Hydrocortisone cream or Benadryl spray or gel on treated areas to reduce itching or redness. To minimize bruising, avoid Aspirin, Anti-inflammatory drugs, Gingko biloba, Garlic, Flaxseed Oil, Vitamin E, Alcohol, spicy food, salty food and cigarettes 72 hours to 1 week after your treatment.
It is normal to feel “firmness” in the injection site first day after treatment. In some cases, a lumpy formation can be felt on the injected area. If necessary, massage area gently 2-3 times a day up to 72 hours.
Do not exercise for 24 hours after treatment. Avoid strenuous exercises, sunbathing or tanning.
Apply sun block and protect skin from sunlight.
For treatment of neck areas, sleep with head elevated (3-4 pillows), and wear some compression under chin (scarf or head band).
Call us immediately if you start experiencing these symptoms or develop any persistent side effect at 813-665-0309.
Electroporation Virtual Mesotherapy Post Treatment
There are no side effects associated with Electroporation treatment
A mild allergic reaction or itching to the fat dissolving serum is rare but possible. Take Benadryl if itching occurs.
- Do not touch the treated area for at least 12 hours post treatment.
- Wait 24 hours to wash the treated area
- Avoid strenuous exercises, sunbathing or tanning for 48 hours post treatment.
- Leave the osmotic wrap on for at least 4 hours post treatment
By my signature, I certify that I have thoroughly read and understand the contents of this form and the disclosures listed above were made to me