Fat-Dissolving Injections Consultation and Consent Form | Aesthetics Forms Portal

Lipolytic Injections Consultation/Consent Form

Client Details

Full Name: *

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Before

Medical History

Do you currently take any medication? *

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Do you have any allergies or intolerances? *

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Are you currently pregnant (or possibly may be) or breastfeeding? *

Do any of the following apply to you? Please tick all that apply.

Acute/untreated hormonal disorder Allergy to substance or materials necessary for the procedure (A full list is available upon request) Autoimmune disease Immunosuppression Active infection Body dysmorphic disorder (BDD)

Do you have any other medical conditions? *

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Have you recently been unwell? *

Which of the following were you unwell with? *

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Emergency Contact Details

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Treatment Information

What are Fat-Dissolving Injections?
They are an injectable fat loss treatment.
They are used for localized or spot removal of fat and is generally regarded as safe. It is not a weight loss solution and is suitable for smaller, stubborn pockets of fat, not large area fat reduction. The amount of treatments needed depends on the size and amount of excess fat in the area.

How does it work?
Fat-Dissolving Injections are a non-surgical way of body-shaping. The solution is injected into areas of unwanted fat. The solution works by disrupting the surface of the fat cells (membrane), causing them to weaken and become permeable. Through the process of the lymphatic system, the fats cells are destroyed and pushed through the body. The fat is then absorbed by the body and excreted. It is a permanent result, assuming the person having the treatment doesn’t gain weight after the treatment.

What’s the treatment like?
Pain is minimal, but can experience injection pain, itching and stinging. Each treatment will take 10-30 minutes depending on the size of the area being treated.

Which areas can be treated?
Suitable for treating: double chin, jowls, upper arms, armpits, waist, hips, knees, chest, inner tights, buttocks as well as folds on the back.

How many treatments are needed?
Some people may see an improvement after 1-2 sessions but up to 8 may be required depending on the amount of fat in the area. Chins, where there is less fat for example, may require one treatment while hips or thighs may require repeated treatments.

Treatments will usually be spaced 4 weeks apart.

Is there any downtime?
There may be redness, bruising and swelling that could last up to 48-72 hours.

The fact of the matter is there are areas of the body and face that do not decrease or tone up even through dieting and regular exercise. Our experience is that with this new technology — fat removal injections — we can shift this stubborn fat when all else fails. Common areas our patients want to transform are the under the chin (the jowls), around the hips (the muffin top), under the upper arms (bingo wings) and the stomach, hips, chest, inner and outer thighs, knees and ankles. Both men and women come to our clinic for this treatment because of its effectiveness.

While fat removal injections are not a great option for larger areas of unwanted fat, they are perfect for people who are at a healthy weight but have a little extra in an isolated area. If you want to remove larger amounts of fat, or are looking to lose a significant amount of weight, non-surgical fat removal treatments are not the best choice. As with any cosmetic weight-loss procedure, it isn’t a substitute for a healthy diet and lifestyle. The removal of specific fat cells will be permanent, but maintaining the reduced fat cells after treatment is down to you. We can’t work miracles if you don’t do the work needed to maintain your treatment.

Are Fat Removal Treatments Safe?
The treatment does not require surgery, and this alone makes it safer than procedures involving going under the knife and a stay in the hospital. We want everyone to know that surgery isn’t your only option now that non-surgical treatments can be just as effective. Surgical treatments like liposuction carry a much greater risk of infection, require more in terms of pre and post-treatment requirements and have longer downtime. The fat-dissolving treatment is the alternative to invasive liposuction and is available near you at a much lower cost.

The side effects of fat loss injections are mild. You may experience some pain, light bruising or swelling around the injection area for a few days after treatment. Please discuss with your registered clinician if you have any doubts whether this treatment is right for you.

I consent to the use of lipolytic fat dissolving solutions that are FDA approved and comparable in safety and efficacy to "known" brand fat dissolvers. I understand the fat dissolving brands used for model treatments are Aqualyx (Deoxycholic Acid)

YES

Aftercare Advice

For the best possible results from your treatment(s) we advise the following:

Avoid Aspirin for pain to reduce the risk of bruising or bleeding. Tylenol/Paracetamol is acceptable. Intermittent cooling with ice can be used by applying for 5 minutes post-procedure. A simple fan can also be helpful for discomfort.
Bruising may occur. Avoid direct sunlight, sunbeds and heat therapies during the treatment period.
Avoid hot baths and showers (tepid water only) for 5 days.
Nodules are not uncommon. They can last up to a month and usually disappear without any intervention. However, your Physician would need to assess anything unusual.
A compression garment may be worn for 2-5 days following treatment (this will be guided by your Physician’s recommendation).
It is best to avoid strenuous exercise and heavy alcohol in the first 24hrs after treatment. Exercise is otherwise acceptable. We would always encourage adherence to recommended guidelines on alcohol consumption, both for general wellbeing and preserving facial/body aesthetics.
Contact your Physician with any concerns without delay.

Please click the box to confirm: *

I have read and understood the aftercare advice on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the treatment(s) to be carried out.

Client Signature: *

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