Mesotherapy Consent Form
Date of Birth:
Filorga HA135 or Skymedics mesotherapy are used for skin glow and hydration.
Common Side Effects Associated with Mesotherapy Treatment
Bruising: Occasionally the needle may puncture a small blood vessel resulting in a bruise.
Swelling and Redness: This may result following the procedure as the medication begins to work.
Uncommon Side Effects
Scarring: Scarring may result from multiple injections, but this is very unlikely.
Allergic reactions: Although exceedingly rare, the possibility exists of an allergic or sensitivity reaction to the Mesotherapy medications.
Discoloration: Transient or permanent skin pigmentation changes can sometimes occur at injection sites.
3-6 sessions are required every 2 weeks and then 1 every 6 months as maintenance.
The successful outcome varies by degree and how long it lasts varies from one individual to another and cannot be guaranteed.
I consent to photographs being published for;
I have been advised the cost of the treatment will be £ and accept the terms of payment as per the clinic policy (terms and conditions).
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Signed by Nina Bal
Signed On: 8th January 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Mesotherapy Consent Form
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