I hereby consent to the Mesotherapy treatment of which I understand that more than one treatment is required. I understand that the treatment requires small injections around the area to be treated. I understand that the administration of topical anesthesia may be used if deemed needed.
I understand that there are some risks with any procedure. Complications of Mesotherapy are rare and usually self-limited, but include the following:
1 Discomfort: Medication is injected with tiny needles just below the skin. There may be brief minimal discomfort from the injections.
2 Bruising: Occasionally the needle may puncture a small blood vessel resulting in a bruise.
3 Swelling and redness: This may result in following the procedure as the medication begins to work.
4 Scarring: Scarring may result from multiple injections, but this is very unlikely.
5 Allergic reaction: Although exceedingly rare, the possibility exists of an allergic reaction to the injection of Mesotherapy medications.
6 Infections: Since Mesotherapy involves injections, there is a theoretical risk of developing an infection at the injection site, this is also exceedingly rare.
7 Discoloration: Transient or permanent skin pigmentation changes can sometimes occur at injection sites.
By my signature, I acknowledge that I have been informed about the above procedure and the medications and give consent use in my treatment.
1. I have met with the doctor who is overseeing my treatment and I have discussed all treatment options available to me.
2. The doctor has informed me and I understand that the results of Mesotherapy are individual and vary depending on the area treated, skin type and the injection technique, and the use of different products. Therefore, no guarantee can be made as to the results of my treatment.
3. I understand that the effects of the treatments with these products can last on average, 3 or more months with complete treatment, but that in some cases duration of the effects can be shorter or longer. Touch-up and follow-up treatments may needed to sustain the desired degree of my treatment.
4. I agree that this constitutes fill disclosure and that I supersede any previous verbal or written disclosures.
5. I understand that this treatment is s strictly for cosmetic purposes and will not be covered by insurance.
6. 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.