MESOTHERAPY CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Do you have any known allergies to medications, vitamins, or injectable substances (e.g., hyaluronic acid)?

Yes

If Yes, please specify:

Do you have any skin infections, inflammation, or open wounds in the treatment area?

Yes

If Yes, please specify:

Are you currently taking any medications that affect bleeding (e.g., aspirin, blood thinners) or have a bleeding disorder?

Yes

If Yes, please specify:

Do you have any chronic medical conditions (e.g., diabetes, autoimmune disorders)?

Yes

If Yes, please specify:

Are you currently pregnant, trying to conceive, or breastfeeding?

Yes

If Yes, please specify:

Do you have any other medical conditions?

Yes

If Yes, please specify:

Procedure Description:

I understand that I am receiving mesotherapy treatment, a minimally invasive cosmetic procedure that involves the injection of small amounts of specialized solutions into the middle layer of the skin (mesoderm).

The injected substances may include a combination of vitamins, minerals, amino acids, hyaluronic acid, and other active ingredients tailored to address specific concerns such as skin rejuvenation, hydration, pigmentation, or hair restoration.

During the procedure, multiple micro-injections are administered into the targeted treatment area using fine needles or a mesotherapy device. A topical numbing cream may be applied beforehand to improve comfort.

The treatment works by delivering active ingredients directly into the skin, stimulating collagen production, improving circulation, and enhancing cellular function.

I understand that multiple sessions are usually required to achieve optimal results, and outcomes develop gradually over time. The procedure may be used on areas such as the face, under-eye area, scalp, or body depending on the treatment goal.

Benefits and Risks:

I have been informed that the potential benefits of mesotherapy treatment may include:

Improved skin hydration and radiance
Reduction in fine lines and mild wrinkles
Enhanced skin tone and texture
Brightening of dull or uneven skin
Targeted treatment for pigmentation or under-eye concerns
Stimulation of hair growth (when used on the scalp)

I understand that there are potential risks and side effects associated with mesotherapy treatment, including:

Mild discomfort or stinging during injections
Temporary redness, swelling, or tenderness at the injection sites
Minor bruising or small bumps (papules) at injection points
Itching or sensitivity in the treated area
Temporary uneven appearance as the product settles

I understand that serious complications are uncommon but may occur in rare cases.

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo a Mesotherapy treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of a Mesotherapy treatment can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the Mesotherapy treatment, except for cases of negligence or intentional misconduct.

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Photographs and records:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Client's Initial

Receptionist's Initial

Technician's Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: