I am requesting that my healthcare provider conduct Mesotherapy/Lipotherapy, using Phosphatidylcholine (PPC) &/or other medications as listed below, a form of Mesotherapy involving subcutaneous injections, which will be referred to as the “Procedure” henceforth. I am requesting the procedure to be performed on: 09/18/2024 

I have reviewed the Information Package for Meso/lipotherapy and have had a discussion with my healthcare provider regarding the Procedure I am about to undergo. I have received an explanation about the nature of the Procedure, potential complications, risks, benefits, alternatives, and the associated risks and benefits of those alternatives in terms that I can comprehend. My healthcare provider has addressed all my concerns about the procedure.

I fully comprehend that this Procedure is an elective aesthetic procedure and that there is no urgent medical condition necessitating the Procedure. Neither my healthcare provider nor the staff has made any commitments, warranties, or guarantees regarding the success or effectiveness of the Procedure.

I acknowledge that the Procedure may not yield the desired results and multiple procedures may be necessary for effectiveness. I am aware that post-procedure, I may encounter side effects such as pain, discomfort, tingling, burning, swelling, and bruising, which may be temporary or permanent. I understand that I may feel dizzy and will inform my healthcare provider and follow instructions to rest. I acknowledge that some of these side effects might be hard to endure.

I understand that there are numerous known and unknown risks and complications associated with the Procedure, including but not limited to localized or systemic infections, bleeding, delayed healing, under or overcorrection, and other unforeseen risks and complications.

I am aware that the Procedure is relatively new, and its long-term safety and efficacy are not fully understood.

I understand that the Procedure does not correct certain health problems including but NOT limited to Diabetes, heart attack or stroke, blood clots, lung problems, stomach or intestinal problems, or bladder disease.

I understand that I will need certain post-procedure care. I will be dutifully responsible in being strictly compliant with the recommendations from my healthcare professional.

I must immediately report any unusual symptoms, know to me, to my healthcare professional and be aware of any slight nature or prominence of persistent chills or fever, redness or increased warmth, excessive bruising or swelling at the site of the injection, fatigue, lethargy, decreased appetite, jaundice, dark urine, unusual severe itchiness or abdominal pain.

I give my healthcare professional permission to use data about my treatment. I understand that my name and personal identifying information will remain confidential unless I give written permission to disclose this information. I give my healthcare professional permission to photograph the procedure.

I understand that Phosphatidylcholine (PPC) is being used in an “off label” use and is not approved by the Federal Drug Administration (FDA). I have decided that the benefits of this form of Meso/Lipotherapy outweigh the potential for complications. I am of clear mind and completely understand the nature of the Procedure and ANY and all possible risks mentions, but NOT limited to all stated risks, which are related to the Procedure.

By signing below, I am indicating that I have read and understood the information in this Patient Consent Form, that I have been verbally advised about the Procedure, that I have had an adequate and reasonable opportunity to ask questions, that I have received all the information I desire concerning the Procedure, all of this information is mentally and physically clear to me, and that I authorize and consent to the performance of the Procedure. I release from all liability the medical professional performing this procedure as well as the facility where it is being done.