FAT DISSOLVING (LIPOLYSIS) CONSENT FORM

Lipolysis can be used as a means of moderate reduction of fat tissue for patients that do not want to undergo surgery. The solution is injected directly into the fat tissue. Administration of anesthesia is usually not required. To date not one single phenomenon of overdose or toxication has been recorded. Intervals between treatments should amount to three to four weeks. The number of treatments can vary between two and eight sittings according to the characteristics of the treated area. As with all aesthetic medicinal therapies there is no guarantee for a fully successful treatment.

General risks: injection therapy may result in permanent damage of nervous tissue and nerves, as well as inflammatory reactions and infections that may result in irreversible scarring.
Expected side effects: swelling and hyperthermia of injected area, hematoma, pressure sensitivity, moderate pain and itching within the treated area.
Possible side effects: redness of the skin that may become permanent, lumps within the tissue, denting of the treated area due to irregular reduction of fat cells, allergic reactions and hyperpigmentation.
I have been informed about alternative therapies such as dietary measures, increased physical exercise or operative correction (e.g. liposuction). I am not considering any of those options at the time of this treatment.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

Pre and post treatment instructions have been explained to me.
I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
I must notify the clinician if my medical history changes prior to subsequent treatments.
I consent to clinical photographs being taken of my treated areas for my personal health record only.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE CLINIC, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.

Patient Name& signature:

Doctor/Therapist Name & Signature:

Witness Name & Signature:

Parent or Gaurdian Name (if patient is minor) :

Date