• MESOTHERAPY SKIN REJUVENATION 

    CLIENT RECORD 
  • Format: (000) 000-0000.


  • PAST HISTORY:

    Prior sensitivity:            


    Collagen disease?           


    Autoimmune disease?           


    Viral infections?          


    Medications?          


    Allergies?          


    Dermatitis?           


    Atopic skin reactions?               
     

    Eczema?               
       


  • MEDICAL HISTORY:
    Please complete the following questionnaire

    Are you pregnant or breast feeding?            

    Have you a history of allergy/anaphylaxis?           


    Are you currently receiving medical treatment?           


    Current medication?          


    Have you ever had peels/laser?               

    When was last treatment?        

    Any problems?           


    Any skin infections?               
     

    Do you use retinol?               

    Details of any allergies?         

    Prescription acne treatments?            

    Sun screen?            

    Hours spent in sun/sunbeds      

    Roaccutane?         

    Pacemaker?         


  • EXCLUSIONARY CRITERIA:

    Active herpes simplex (cold sores):            

    Recent wounds?           


    Recent radiation?           


    Hypertrophic/keloid scars?          


    Warts?          


    Recent cryotherapy?          


    Other?      


  • INDICATIONS FOR TREATMENT:

    Skin texture      
    Surface laxness      
    Skin brilliance      
    Hyperpigmentation      
    Pore size      
    Fine wrinkles      
    Acne      
    Skin tone      
    Sun damage       

  • Treatment Advice for Clients

     

    Contraindications to Mesotherapy

    Pregnancy and breast feeding

    Roaccutane

    Laser treatment

    Broken skin

    Sunburn

    Acitve Eczema/psoriasis

    Chemotherapy and radiation

    Active herpes

     

    Post Treatment Advice

    If any redness persists do not go back to using glycolic acid until it is resolved

    Skin may feel drier or tighter – this is quite normal. Use extra moisturiser

    Do not use a sunbed, sunbathe, sauna or steam bath for 24 hours days after mesotherapy

    Always use recommended sun protection

    Avoid electrolysis, waxing, bleaching (face) for 36 hours

    Do not swim in chlorinated water for 3-5 days

    No excessive exercise immediately after

    Make up can be applied, mineral is recommended

    Take directed advice if undergoing laser or IPL treatment 

  • Patient consent for mesotherapy injectable products – facial rejuvenation

    This product contains a cocktail of vitamins, minerals, amino acids and hyaluronic acid. It is designed to boost cell turnover, hydrate and provide essential extra supplements to the skin. It is delivered by a series of very superficial (barely breaking the skin), micro-needling. The procedure at worst can be described as mildly uncomfortable.

    Common side effects

    • Redness & flushing • Swelling & pain • Tenderness & itching • Bruising & bleeding

    These typically resolve within minutes, sometimes hours and rarely days after treatment. Extremely rare side effects may include infections and ulceration.

    I am 18 years or older, I am not pregnant or breast feeding.

    I understand that the practice of medicine and surgery is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.

    The procedure for mesotherapy has been explained to me by the practitioner. I have read and understand the information given to me. I consent to undergo treatment. 

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