Mesotherapy Consent Form

MESOTHERAPY AFTERCARE
The following aftercare advice is essential to help reduce the risk of treatment
complications, to improve your comfort/healing and to help achieve the best possible
results from treatment.
Please follow the aftercare advice for mesotherapy.
• The treated area of skin may feel slightly tender and appear red and swollen
afterwards. These effects will resolve naturally and should be much improved
after 48 hours but may take longer to settle. You may experience some minor
bruising which may take 1-2 weeks to resolve in some cases.
• Use of a cold compress for swelling and arnica cream for bruising may be helpful
for resolution.
• Avoid any perfumes, fake tan or other harsh chemicals for 72 hours after
treatment.
• Avoid any makeup for 24 hours after treatment as this can increase the risk of
infection.
• Avoid rubbing or picking the treated area.
• Avoid any skin exfoliation for 72 hours following treatment.
• It is important to use a regular moisturising cream around two to three times a
day on the treated area. Use more regularly if you feel the skin dry or peeling.
• Avoid any products that contain alpha hydroxy acids, retinol, and glycolic acid for
at least 7 days after treatment.
• Avoid strenuous exercise, saunas, sunbeds and exposure to heat for 72 hours
after treatment. These can cause sweating which can irritate the delicate skin
and slow down your ability to heal quickly.
• Avoid swimming for 72 hours after treatment.
• Avoid any excess alcohol or caffeine for 48 hours after treatment.
• Wear SPF 30 or greater sunscreen for at least 2 weeks following treatment as
your skin will be more sensitive to sunlight afterwards.
• Avoid any further cosmetic treatments e.g. Botox or dermal filler for 2 weeks
following treatment, or ask your practitioner for advice.
• Avoid any hair removal treatments such as waxing for 2 weeks after treatment or
until the initial redness and swelling has resolved.
• You must seek medical attention and contact your practitioner if you experience
any signs or symptoms of infection after treatment. Infection can present as hot,

red shiny skin, there may be pus formation and you may have a fever or feel
generally unwell.
• You must seek emergency medical attention if you experience any severe allergy
symptoms or features of anaphylaxis. These may include rash, breathing
difficulties and facial swelling.
• You must contact your practitioner as soon as possible if you notice any other
unwanted side effects.
• Your practitioner will advise when further treatment appointments are required. If
you are advised to attend a follow up appointment, please do make every effort to
attend them. You should do this even if you believe that the recovery process is
going well and you cannot see that there are any visible complications.
It is essential that you have read all of the information available. Once you have read and
understood all of the below, please sign the declaration at the bottom of this form. Please
do let your practitioner know if you have any questions or if you do not understand any of
the aftercare instructions provided below.
I confirm that I have read and understood all the information on this Form and that I have
been given the opportunity to ask any questions that have come to mind throughout.

Mesotherapy Consent Form

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of mesotherapy. 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.

Mesotherapy is a technique that uses customised mixtures of vitamins, herbal extracts, enzymes, amino acids, and/or other medications placed with fine needles, just millimeters into the middle layer of the skin. Mesotherapy is used for cosmetic purposes such as skin rejuvenation as well as fat and cellulite removal.

Uses of mesotherapy include cellulite reduction, removal of fat in multiple body areas, body recontouring, skin rejuvenation and tightening, treatment of treat fine lines and wrinkles and areas of hyperpigmentation.

Many different formulas exist for the substances injected during mesotherapy; your practitioner will discuss the options that are available to you. Any formulas that contain prescription only medications your practitioner will organise a prescription consultation with a medical doctor of prescribing nurse. If your practitioner is a prescribing medic then this would not be required. It is important that you complete all the below questions and inform your practitioner of any allergies and medical problems you have.

I am aware that results vary between clients and results are dependent on many individual factors. The time of onset for visible results and the duration of results again varies between clients and depends on other factors such as the aim of treatment. I am aware that there is no guarantee that I will achieve desired results and that multiple treatment courses may be needed to achieve or maintain desired results. I am also aware that this treatment is cosmetic and is not designed to cure any medical condition or act as a substitute for medical care. For any medical conditions I have seen my doctor for diagnosis and management. I understand the treatment is most successful when combined with diet and exercise. Results of fat loss will only be maintained so long as you continue to not gain further body fat after the treatment course.

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: As with any procedure there are potential risks and complications associated. You must be aware of all the following risks before proceeding and fully discuss any questions with your practitioner.

Common risks include some mild pain or discomfort, the skin may appear red or swollen afterwards, this should settle normally within 48 hours. You may experience some minor bleeding or bruising that will resolve naturally. You may experience some mild irritation at the treatment site. Sometimes people can faint or feel faint with needles, you must tell your practitioner as soon as possible if you feel unwell during the treatment.

Uncommon risks include skin infection (cellulitis), reactivation of cold sores (herpes simplex infection), temporary changes in skin pigmentation to lighter or darker which should usually resolve within 6 months. Temporary bumps or unevenness at the treatment site.

Rare risks include permanent skin pigmentation changes, permanent skin scarring, allergic reaction to a constituent of the mesotherapy formula injected. Allergic reaction usually presents as swelling and red rash however in extremely rare cases clients can develop an anaphylactic reaction. This is life threatening and would require emergency medical attention.

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 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.