Facial Sculpting

Mesotherapy Consent Form

Patient Name:  

Date of Birth:  

Mesotherapy Consent Form

Filorga HA135 or Skymedics mesotherapy are used for skin glow and hydration.

Common Side Effects Associated with Mesotherapy Treatment

  • Discomfort

  • 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.

  • Infection

  • 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.

Permissions Requested

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

Signature Certificate
Document name: Mesotherapy Consent Form
Unique Document ID: 5cf56000b501fc4ad9e09b484ce8b1965db38689
Timestamp Audit
7th November 2019 3:30 pm BSTMesotherapy Consent Form Uploaded by Nina Bal - info@facialsculpting.co.uk IP