Facial Sculpting

Pluryal Mesoline Consent Form


1. Medical history of the Patient:

Name Phone Age  

Address  
City Postal Code  Country  

Email address  

DRUGS:  

ALLERGIES:  

Female Patients: Are you pregnant or breastfeeding?  

Doctor’s Name  

 

Tick one or several answers of conditions you have known in the past:

Elaborate:

 

2. General Information:

As my patient, you have accepted that I proceed to the cutaneous application of the product PLURYAL MESOLINE (Refresh, Shine, Tight, Antiox, Clear, Hair, Facecontour, Bodycontour or Bodyfirm), a family of sterile cosmetic products destined at improving the skin or hair condition, through several sessions which are planned according to individual needs.

x PLURYAL MESOLINE REFRESH is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of hyaluronic acid, extracts of pisum sativum as well as vitamins, and is recommended as an anti-aging treatment for skin presenting loss of tone, glow or elasticity.

x PLURYAL MESOLINE TIGHT is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of dimethyl MEA, panthenol, ferulic acid and silanetriol is recommended to treat the loss of firmness, first sign of the aging.

x PLURYAL MESOLINE SHINE is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of ethyl ascorbic acid, pyruvic acid, phytic acid, kojic acid and extracts of mulberry leaves, targets several signs of the skin aging: dull skin, non-homogeneous complexion and brown spots.

x PLURYAL MESOLINE ANTIOX is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of antioxidants (glutathione, mannitol and acetyl cysteine) proline as well as zinc gluconate, is recommended for aggressed and tired skin.

x PLURYAL MESOLINE CLEAR is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of retinyl palmitate, ginkgo biloba, a Vitamin B complex as well as hyaluronic acid, is recommended for acne-prone skin.

x PLURYAL MESOLINE HAIR is a sterile solution supplied in a vial of 5ml, for single use. This formulation, specifically elaborated for hair, is composed of copper peptide, vitamins, amino acids, antioxidants and extracts of pisum sativum as well as hyaluronic acid.

x PLURYAL MESOLINE FACECONTOUR is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of deoxycholic acid, aesculus hippocastanum, equisetum arvense and ginkgo biloba, is recommended for the skin shaping.

x PLURYAL MESOLINE BODYCONTOUR is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of deoxycholic acid and phosphatidylcholine, is recommended for the skin shaping.

x PLURYAL MESOLINE BODYFIRM is a sterile solution supplied in a vial of 5ml, for single use. This formulation composed of carnitine, caffeine, artichoke, extracts of ruscus aculeatus, centella asiatica as well as methylsilanol mannuronate, has a skin smoothing action.

Any medical or aesthetic act can present risks and provoke complications. The purpose of this for mis to inform you prior to the session about the nature of the procedure and the risks that could be associated to it.

3. Procedure :

The Pluryal mesoline products are applied to the skin or scalp, after a through disinfection of the skin or scalp, using a disinfecting solution. They can be administered through transdermal delivery machines, using technologies such as mesoportaion, ultrasounds or electroporation.

It is necessary to repeat the sessions several times (5 to 8 times), at weekly or 10-days intervals and to proceed to annual sessions of follow-up, defined according to individual needs. After the session, it is necessary to protect the skin from the sun, using a total sunblock cream, and to renew the sunblock application every two hours in case of prolonged sun exposure. This protection is recommended for 15 days following the sessions.

4. Risks & Complications:

Every product application could provoke allergic or sensitive reactions. Pluryal mesoline products have been tested under dermatological control and have shown an excellent tolerance when they are applied on healthy skin.

5. Contra-indications to Pluryal Mesoline products:

The Pluryal Mesoline products should not be used in patients: x Presenting antecedents of auto-immune diseases or those receiving an immunity treatment. x Known as showing a hypersensitivity to one of the actives present in the formulations x Pregnant or breastfeeding women x Below the age of 18 years.

6. Photographs:

I, the undersigned, voluntarily consent to the taking, publication and use of my pictures, after every visit according to the scheduled protocol.

7. Consent :

A copy of this form was given to you. Your consent and authorization to receive the treatment are totally voluntary. By signing this consent form, you agree that your doctor proceeds to 5 – 8 sessions of Pluryal Mesoline. The nature of this procedure, the alternative methods possible as well as the complications were all explained to you. No guarantee of results has been promised to you.

I have read carefully this consent form and have understood what it explains. I have taken sufficient time to read the given information and agree that I have been sufficiently informed about the procedure through this consent form. I hereby grant my consent to this procedure by signing the form, following my discussion with my practitioner.

Leave this empty:

Signed by Nina Bal
Signed On: 8th January 2020

Signature Certificate
Document name: Pluryal Mesoline Consent Form
Unique Document ID: 783aafb8c692f85fec14834010982e5c89307c9a
Timestamp Audit
22nd November 2019 1:03 pm BSTPluryal Mesoline Consent Form Uploaded by Nina Bal - info@facialsculpting.co.uk IP 51.179.98.227