Mesotherapy Consent Form

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Patient Information

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Mesotherapy/Lipo Dissolve (Fat Dissolve) & Slim Cellulite Injections or by Hylauron Pen Patient Informed Consent and Disclaimer

Mesotherapy/Lipo Dissolve (Fat Dissolve) & Slim Cellulite Injections or or by Hylauron Pen Patient Informed Consent and Disclaimer

Mesotherapy & Fat Dissolve or a regional intradermal therapy consists of intradermal or subcutaneous injections

During this procedure, you receive a series of injections in the area(s) with cellulite. Different substances are injected into the area, including caffeine, & enzymes, and herbal extracts. not exceeding 12 injections to site. Follow Up in 21 days and after 3 visits 28 day follow up recommended.

Hylauron Pen, distributes product in an air socket pen to dissolve fat without needles, all after and pre care are the same.

What is mesotherapy? Mesotherapy is the administration of substances that are only injected locally. The amount of medication is very small and is administered through the use of super-fine, short needles which allow for micro-injections throughout the area to be treated. The pharmacological action is maintained thanks to the repeated administration.

Do the substances used in mesotherapy cause intolerance and allergies? The medications that are used for mesotherapy are the same as those that are normally used systemically; it is therefore the doctor’s responsibility, with a careful medical history, to evaluate whether there are grounds for a potential allergy.

In the treatment of cellulite, or fat dissolve mesotherapy mesotherapy should in principle act on:

  • Improved circulation with a draining and detoxifying effect
  • Firming the skin by stimulating the normal physiological production of collagen and elastin,
  • Fat loss, and slight tighten, if fat is present

improving the appearance of “orange peel” skin

  • Fat reduction when present

Which parts of the body can be treated with mesotherapy for cellulite?

Areas that can be treated with mesotherapy include:

  • The upper and lower abdomen
  • The hips
  • The outer thighs (“saddlebags”)
  • The thighs
  • The knees
  • The arms
  • Fatty facial areas

A course of treatment of around 3 sessions every 21 days is required, along with any necessary monthly maintenance sessions If necessary and dietary changes don’t occur.

Mesotherapy for cellulite: is it painful? What are the side effects?

  • Mesotherapy is mildly uncomfortable
  • You may sometimes feel a slight burning sensation (depending on the medication)
  • Some bruising or bleeding

When do you see the results of mesotherapy?

Depending on the type of cellulite, on average, you start to see an improvement after 3 to 5 sessions.

How long does the effect of mesotherapy for cellulite last?

The results last if you maintain a healthy lifestyle, with proper nutrition and physical activity, otherwise they may be cancelled out. Cellulite must be considered a disease to be kept under constant control.

Who is a good candidate for mesotherapy for cellulite?

The best candidates for mesotherapy are:

  • Those with localized fat deposits
  • Those with cellulite in the early stages
  • Those who combine diet and exercise

TREATMENT CARE INSTRUCTIONS Pre-Treatment Recommendations

● 7 DAYS BEFORE treatment (to prevent bruising): Avoid blood thinning over-the-counter medications such as Aspirin, Motrin, Ibuprofen, and Aleve. Also avoid herbal supplements, such as Garlic, Vitamin E, and Omega-3 capsules. Please note: If you have a cardiovascular history, please check with your doctor prior to stopping use of Aspirin.

● Plan your treatment accordingly as for most aesthetics procedures. Post-injection site bruising is common with SLIM treatment related to its natural enzymatic reaction with the fibrous bands of the cellulite. We recommend you to plan your treatment around the time you might want to wear a bikini or swimsuit, etc.

● Do not drink alcoholic beverages 24 hours before (or after) your treatment to avoid extra bruising.

● Do not have SLIM treatment if you are pregnant or breastfeeding, are allergic to collagenase, or suffer from any bleeding disorders. Post-Treatment Recommendations

● Majority of the patients experience bruising after first treatment, and the severity of bruising subsequently lessens after each additional treatment session. The bruising is related to the mechanism of action of SLIM and not to the process of injection.

● You may Ice the area for the first 2 days, apply warm compress afterward to facilitate. But in general, our body will absorb and untreated bruising will fade in 10 to 14 days.

● AVOID aspirin or ibuprofen products as they may increase your potential to bruise.

● You might experience minor pain, itchiness at the injection site. You may take Acetaminophen/Tylenol if you experience any mild tenderness or discomfort.

● There is no limitation on exercise or activity after treatment.

● There is no need to RUB OR MASSAGE the treated area(s).

● AVOID drinking alcohol for a minimum of 24-48 hours as this may contribute to bruising and/or swelling.

● AVOID extended UV exposure until bruising has subsided. Be sure to apply an SPF 45-50 or higher sunscreen.

● We recommend that you schedule your next treatment in 21 days and return to our office 28 days after completion of the three (3) sessions for the final assessment of the result.

Hylauron Pen & Fat Dissolve or By needles

Can be infused with Hyaluron Pen, most recommended with 0.5ml disposable syringes. Kabelline can be used on the chin, arms, legs, belly, hips, and all body parts (not to be used on the cheeks).

Slim Cellulite Injections,

  • Increases the drainage effect in the treatments of cellulite and localized fat
  • Removes excess water from the skin, moves fats to facilitate their elimination, INGREDIENTS: Water (aqua), Caffeine 3%, Maltodextrin, Propylene Glycol, Xanthan Gum, Hydroxyethyl cellulose, Centella Asiatica extract, Fucus Vesiculosus extract.

TREATMENT CARE INSTRUCTIONS Pre-Treatment Recommendations

● 7 DAYS BEFORE treatment (to prevent bruising): Avoid blood thinning over-the-counter medications such as Aspirin, Motrin, Ibuprofen, and Aleve. Also avoid herbal supplements, such as Garlic, Vitamin E, and Omega-3 capsules. Please note: If you have a cardiovascular history, please check with your doctor prior to stopping use of Aspirin.

● Plan your treatment accordingly as for most aesthetics procedures. Post-injection site bruising is common with SLIM treatment related to its natural enzymatic reaction with the fibrous bands of the cellulite. We recommend you plan your treatment around the time you might want to wear a bikini or swimsuit, etc.

● Do not drink alcoholic beverages 24 hours before (or after) your treatment to avoid extra bruising.

● Do not have SLIM treatment if you are pregnant or breastfeeding, are allergic to collagenase, or suffer from any bleeding disorders. Post-Treatment Recommendations

● Majority of the patients experience bruising after first treatment, and the severity of bruising subsequently lessens after each additional treatment session. The bruising is related to the mechanism of action of SLIM and not to the process of injection.

● You may Ice the area for the first 2 days, apply warm compress afterward to facilitate. But in general, our body will absorb, and untreated bruising will fade in 10 to 14 days.

● AVOID aspirin or ibuprofen products as they may increase your potential to bruise.

● You might experience minor pain, itchiness at the injection site. You may take Acetaminophen/Tylenol if you experience any mild tenderness or discomfort.

● There is no limitation on exercise or activity after treatment.

● There is no need to RUB OR MASSAGE the treated area(s).

● AVOID drinking alcohol for a minimum of 24-48 hours as this may contribute to bruising and/or swelling.

● AVOID extended UV exposure until bruising has subsided. Be sure to apply an SPF 45-50 or higher sunscreen.

● We recommend that you schedule your next treatment in 21 days and return to our office 28 days after completion of the three (3) sessions for the final assessment of the result.

I am requesting that my health care professional perform Mesotherapy/Fat Dissolve/ Hylauron Pen, using Phosphatidylcholine (PPC) and/or other medications listed below, a form of Mesotherapy using subcutaneous injections, that will be referred to as the "Procedure" in the following. I am requesting the procedure to be performed on (Choose area) the sides of the abdomen, thighs, upper arm, chin, neck, infraorbital (fat pad below the eyes), buttock area, area between bra straps and underarms, above the knee; (state precise location)

I have reviewed the Information Package Mesotherapy/Fat Dissolve/ Hylauron Pen, have discussed the Procedure that I am to receive with my health care professional.

The nature of this Procedure, the possible complications and risks, as well as the possible benefits of the Procedure, the alternatives to the Procedure and the risks and benefits for those alternatives have been explained to me in language and using terminology that I understand. My health care professional has personally answered all of my outstanding questions about the procedure.

I fully understand that this Procedure is an elective aesthetic procedure, and that there is no emergency medical condition that requires that I have the Procedure.

Neither my health care professional nor the staff has many any promises or warranties or guarantees as to the success or effectiveness of the Procedure.

I understand that the Procedure may not be effective. I have been advised that I may need several procedures for this Procedure to be effective.

I understand that after the Procedure. I may experience side effects such as pain, discomfort and tingling, burning, swelling, bruising, which may bc temporary or permanent. I ant aware that I may experience dizziness and I will notify my health care professional and agree to lie down as Instructed. I have been advised that I may find some of these side effects difficult to tolerate.

I understand that there are numerous risks and complications, both known and unknown, connected with the procedure. These can include by not be limited to infections that can be localized or could spread throughout my body, hemorrhage or bleeding, delayed healing, under or over correction and other risks and complications, that are unknown at this time.

I understand that the Procedure is a relatively new procedure and that little is known about its long-term safety and effectiveness. I understand that the Procedure does not correct certain health problems including but NOT limited to Diabetes, heart attack or stroke, blood clots, lung problems, stomach or intestines problem, or bladder disease.

I understand that the field Mesotherapy/Fat Dissolve/ Hylauron Pen, continuing to evolve and that if l were to postpone my Procedure there is the possibility that new procedures and ingredients of Meso/Lipotherapy might be improved or some other procedure might become available.

I understand that I will need certain post-procedure care. I will be dutifully responsible in being strictly compliant with the recommendations from my health care professional that may include, but are not limited to ice and compression dressings, etc.

I must immediately report any unusual symptoms, know to me, to my health care professional and be especially aware of any slight nature or prominence of persistent chills or fever, redness or increased warmth, excessive bruising or swelling at the site of the injection, fatigue, lethargy, decreased appetite, jaundice (yellowing of skin or the whites of the eyes) dark urine, unusual severe itchiness or abdominal pain.

I give my healthcare professional permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential, unless I give written permission to disclose this information. I give my healthcare professional permission to photograph the procedure.

I understand that Phosphatidylcholine (PPC) is being used in an "off bale" use and is not approved by the Federal Drug Administration (FDA).

I have decided that the benefits of this form Mesotherapy/Fat Dissolve/ Hylauron Pen, the potential for complications. I am of clear mind and completely understand the nature of the Procedure and Any and all possible risks mentions, but NOT limited to all stated risks, which are related to the Procedure.

By signing below, I am indicating that I have read and understood the t in this Patient Consent Form that I have been verbally advised about the Procedure, that I have had an adequate and reasonable opportunity to ask questions, that I have received all the information I desire concerning the procedure, all of this information is mentally and physically clear to me, and that I authorize and consent to the performance of the Procedure.

I have read, initialed, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily. I understand this procedure and accept all risks and will notify TNT of any changes that could put my treatment at risk, I hereby. release The Natural Place, Dr. Copeland, Dr. Buford & Bridget Hahn and staff from all liabilities associate with the indicated procedure.

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