Facial Consent Form 24

FACIAL MESOTHERAPY CONSENT FORM
Practitioner Details
Dr Name & :
Surname Practice :
Name Practice :
Number Practice :
Address Practice Num :
Telephone -
ber
Emergency Number :
1. I _______________________________________________________________, hereby give consent to
Dr____________________________________________________________________ to perform a facial
mesotherapy injection procedure. I also consent to any other medical services during the procedure that
may become medically reasonable and necessary. This includes, but is not limited to, the administration of
anaesthetics necessary to perform mesotherapy injections.
2. I have declared that I have allergies to:
__________________________________________________________________________________
3. I have declared my current medication I take on my client information sheet and noted any new changes
in my medical condition ___________ (Patient Initials)
4. I understand that mesotherapy can be used to treat various conditions. I fully understand the results that I
may reasonably expect. I understand that not all patients get an aesthetically improved outcome.
5. I, ___________ (Patient Initials) declare that I do not have any of the following contraindications:
Current infections Lupus or Porphyria
Current cancer / chemotherapy Abnormal platelet function
Liver disease Current use of corticosteroid or ana-

bolic steroids
Severe metabolic disorders Anti-coagulant therapy
Skin diseases Steroid injections in the last 2 months

in treatment area
[email protected] www.aestheticdoctors.co.za
6. An explanation of the procedure has been given to me. I understand that micro-injections of a Mesother-
apy cocktail (hyaluronic acid, amino acids, vitamins, minerals, and antioxidants) for anti-ageing and
facial rejuvenation will be injected to the area treated.
7. It has been explained to me that the single ingredients /medicines in mesotherapy preparations are FDA
approved, but that the route of administration intradermal has not been FDA approved for all the ingre-
dients, this constitutes not only an “off table” use of these medications, but also a “non-approved indica-
tion” I understand what this means: __________ (Patient Initials)
8. I am aware of the pros, cons, and alternatives to mesotherapy injections. I understand that the mesother-
apy injection procedure is an “elective” procedure. Alternatives to mesotherapy include PRP, Chemical
peels. Laser resurfacing, skin boosters and radio-frequency procedures.
9. I agree that the procedure recommended is the best recommendation at the time of consultation.
I agree these recommendations may later need to be modified depending on future results and changes in
my own goals or technology.
10. I understand that for optimal result I will need a minimum of 3 procedures.
Furthermore, I understand that additional mesotherapy injection procedures may be needed for a desired
result and that some individuals would expect 1-3 sessions per year for maintenance.
SIDE EFFECTS
i. Dizziness and feeling faint (rare)

ii. A temporary headache
iii. Redness in the treatment area for 2-4 days
iv. Swelling, discolouration, sometimes pigmentation issues, hyperpigmentation, or hypo pigmentation.
v. Reaction to local anaesthetic if used or the ingredients in the mesotherapy mixture.
vi. Infection (rare)
vii. Itching at the injection sites
viii. Minor bleeding and bruising at the sites of injections
11. I consent to having my photos taken. These include pre-procedure (‘before’) photos, photos during the
procedure (‘during’) and post-procedure (‘after’) photos. Photos are to be obtained for my chart and
for purposes of documentation of surgical outcomes.
12. I believe that I have been well informed. I understand that good results are expected, but the practices
of medicine and surgery are not exact sciences. I understand that knowledgeable practitioners some-
times disagree as to the best methods of treatment to achieve desired results.
13. I understand that the success of the mesotherapy procedure is dependent on my closely following all
instructions. This includes but is not limited to, pre- and post-procedure activities and precautions.
14. I understand how to contact Dr ________________________________________________________

should I have any concerns and understand that I have been given his/her emergency contact number which
I can use at any time.
Excessive cigarette smoking (nicotine) limits the results and longevity of the procedure and may
require more and or more frequent treatments.
15. I certify this form has been read or it has been read to me, the blank spaces have been filled in, and I
understand its contents. I was given the opportunity to ask questions about mesotherapy.
16. I have disclosed all information regarding past and present medical conditions, current medications and
known drug allergies.
17. I acknowledge that I am responsible for payment of these services with no fee reimbursement regardless of
procedure results. I understand the fee paid is for the procedure and not for an expected result.
I have read the above information and therefor give my consent to the facial mesotherapy injection
therapy by
Dr__________________________________________________________________________
Signature Patient Date
I, Dr _________________________________________________________________________________
certify that on this date I have observed the patient carefully read and signed this consent form of his/her
own free will.
Signature Medical Practitioner Date

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FACIAL MESOTHERAPY CONSENT FORM

1. I _______________________________________________________________, hereby give consent to

Dr____________________________________________________________________ to perform a facial

2. I have declared that I have allergies to:

Current infections Lupus or Porphyria

Current cancer / chemotherapy Abnormal platelet function

Liver disease Current use of corticosteroid or ana-

Skin diseases Steroid injections in the last 2 months

i. Dizziness and feeling faint (rare)

14. I understand how to contact Dr ________________________________________________________

Signature Patient Date

Signature Medical Practitioner Date

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