LIPO DISSOLVE CONSENT FORM

Name:

Date of birth:

Tel:

Do you have any allergies:

If Female, are you currently pregnant or planning or breastfeeding?

YES / NO

Are you on blood thinning medications?

YES / NO

I, (your name) ___________________________________________________

Have discussed the risks, benefits, and the cost of Lipo dissolve (PTC) with Dr Louisa Yim.

I understand this is a cosmetic procedure and I am aware that PTC works by getting rid of resistant fatty / adipose tissue. My weight, however, will remain the same.

I give consent to have the choice of anaesthetic: TOPICAL CREAM / LOCAL infiltration

I give consent to have the following areas treated:

*

*

I am aware of potential side effects, and that I may need to take TIME OFF work depending on the areas treated. Some of the side effects discussed are:

- Pain, swelling +++ (esp around face), itchiness, redness around site of injection or from topical anaesthetic, bruising or haematoma, nodules, infection (uncommon), tiredness.

Other uncommon side effects discussed are:

- Uneven results, poor or no results (<10% clients due to inherited reduction in receptors to break down PTC), nausea, diarrhoea, sweating, altered tastes and very rarely, palpitations.

I have discussed all the medications/herbal supplements that I am taking.

I am not aware of any contra-indications that may prevent this treatment:

Pregnancy, Breast Feeding, previous Allergic reactions, liver, heart or kidney disease, active infection.

I understand the post treatment care plan and will follow the instructions as directed.

I have read the above information and I am happy to proceed.

Signed: Date: