Healthcare Mesotherapy Treatment Form

Healthcare Mesotherapy Treatment Form

Patient Information

Date of Birth:   Gender:

Primary Phone:   Email:

Relationship:   Phone:

Insurance Information (if applicable)

Policy Number:   Group Number:

Treatment Details

Intended Treatment Date:   Practitioner:

Medical History & Current Medications

Are you pregnant or attempting to become pregnant?   Do you use anticoagulant medication?

Contraindications and Risk Acknowledgement

The patient represents that they do not have, or has disclosed, the following conditions. Please check if applicable:

Active skin infection at treatment site
History of keloid or hypertrophic scarring
Autoimmune disorder or immunosuppression
Current or recent chemotherapy/radiation therapy
Isotretinoin (Accutane) within last 6 months
Cardiac pacemaker or implanted electronic device

Procedure Explanation, Risks, and Benefits

Mesotherapy is a minimally invasive treatment involving microinjections of medications, vitamins, hyaluronic acid, or other compounds into the superficial or middle dermis for therapeutic or cosmetic purposes. Benefits may include localized fat reduction, skin rejuvenation, improved texture or tone, and symptomatic relief where indicated. Results vary and are not guaranteed.

Potential risks include, but are not limited to: transient swelling, bruising, redness, pain at injection site, infection, allergic reaction, nodules, pigmentary changes, scarring, vascular occlusion, and systemic adverse reactions. Rare but serious complications may occur. The patient has the right to refuse any component of the treatment.

I acknowledge that the practitioner has explained the proposed mesotherapy protocol, alternative treatments, expected outcomes, and possible complications. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

Consent and Authorizations

Patient Name:

By signing below I consent to receive mesotherapy treatments administered by authorized clinical personnel under the supervision of the named practitioner. I authorize the use of prescribed substances as described by the practitioner for the purpose of the procedure. I understand that no warranty or guarantee has been made regarding the results.

I authorize the practitioner and clinic to obtain, use, and disclose my protected health information, as necessary, for treatment, payment, and healthcare operations related to this procedure and appointment scheduling. This authorization includes photographs and clinical images for treatment documentation and quality assurance. Photographs used for educational or marketing purposes will be de-identified unless I provide separate written consent for identifiable use.

I understand I may withdraw this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. This authorization will expire on:

Photography consent for de-identified clinical documentation: I consent   Photography consent for identifiable use (separate form required): I do not consent

Post-Treatment Care & Acknowledgement

I acknowledge that I have received verbal and written aftercare instructions appropriate to the treatments provided, including wound care, activity restrictions, and signs of complications that require immediate medical attention. I agree to follow these instructions and to notify the clinic if unexpected adverse events occur.

I accept financial responsibility for treatment and related services rendered. I understand that charges for products or procedures not covered by insurance are my responsibility and that payments due on the day of service are required unless other arrangements are made in advance.

Patient initials acknowledging receipt of pre-treatment instructions:

Acknowledgement of Understanding

By signing this form I certify that the above information is accurate to the best of my knowledge, that I have disclosed all relevant medical history and medications, and that I understand the risks, benefits, and alternatives to mesotherapy. I agree to hold harmless the practitioner and clinic for known and disclosed risks, except in cases of negligence or willful misconduct.

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