• Client Intake & Medical History

    FAT DISSOLVING TREATMENT
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • What are your area's of concern for treatment?*
  • Have you ever received a fat dissolving treatment before?*
  • Have you had any recent cosmetic treatments/procedures within the last 3 months?*
  • Are you currently taking any blood thinning medication?*
  • Do you have issues with fluctuating weight?*
  • Have you taken Isotretinoin medication within the last 6 months?*
  • Do you smoke?*
  • Do you drink alcohol on a regular basis?*
  • Are you currently..?*

  • Medical History

    Please check all that apply
  • Have you ever had an allergic reaction to any of the following?*
  • Check the conditions that apply*

  • Consent and Liability Wavier

    Initial each section.

  • Hyaluron Fat Dissolve Treatment (also known as Injection Lipolysis) remove subcutaneous fat by targeting localized areas of fat not amenable to diet and exercise. Using a synthetic form of deoxycholic acid, fat cells are broken down and flushed out of the body via the lymphatic system. Many areas of the body can be treated, including double chin, abdomen, flanks, inner/outer thighs, back and under arms. Typically, several treatments are required for optimal results.

    Please read and initial the following statements:

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