MESO-NEEDLING CONSENT FORM

Before the treatment, please read this document carefully!  Don’t hesitate to ask questions if you feel the information is not clear. Doctor JD will be available to answer your questions.

Please, take the time you need before making your decision!
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Full Name  *
Email Address *
Please ensure your email address is typed correctly!
Your Current Address 
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Phone Number
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Date Of Birth
Have you suffered from any medical conditions? 
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Are you taking any medications? If so, please specify below:  
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Do you suffer from any illness e.g. diabetes, angina, epilepsy, hepatitis, autoimmune disease?
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Do you suffer from keloid or hypertrophic scars?
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Have you undergone a laser resurfacing or skin peel in the last 6 weeks?
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Will you use a topical sun protection product with an SPF 50 or higher and with stated UVA protection on a daily basis with regular applications for the same period?
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Do you have any allergies?     
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Do you have a blood clotting disorder/ require anti-coagulant treatment?      
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Are you pregnant, planning a pregnancy or breast feeding?         
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I am voluntarily consenting to a Meso-Needling procedure of the skin. I understand that the procedure can result in an appearance enhancement and is typically used for skin rejuvenation and scar repair and that the treatment uses Meso-Needling medical device that creates controlled micro-surgical needle punctures of the skin surface. I also understand that I may require a series of Meso-Needling treatments, normally with at least 6 weeks between procedures, to achieve the maximum cosmetic result. I acknowledge that no written or implied verbal guarantee, warranty, or assurance has been made to me regarding the outcome of the procedure.

I understand the following:
That immediately after the Meso-Needling procedure the skin will be red, resembling moderate sunburn, as the skin naturally heals the redness will resolve. The skin may remain red for three or four days after the Meso-Needling treatment, although it is usual for it to subside within two days and many people are able to return to their normal activities the same or next day. It is recommended that the use of soaps on the treated skin area is restricted until the redness subsides and where possible warm/tepid water and/or gentle skin cleansers are used for cleansing.

There is a small risk of infection of the treated skin area after the Meso-Needling procedure although this is not expected to occur due to the sterility of the Meso-Needling medical device and the fact that the epidermis of the skin is not removed as a result of the procedure.

The Meso-Needling procedure can cause areas of bruising although this would not normally be expected to occur, the eye contour being most at risk. Any bruising will be temporary. There is a small risk that hyper-pigmentation of the skin can occur after the procedure, although this is not normally expected as the epidermis of the skin is not removed as a result of the procedure. Failure to follow the sun expose and sun protection advice detailed below can increase this risk.
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I understand that there are certain risks associated with Mesoneedling. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions
and those questions have been answered to my satisfaction. I fully understand the treatments conditions and procedure.
I understand that the treatment requires many small injections around the area (s) to be treated. I also understand that the administration of numbing cream may be used if deemed necessary. I understand that the benefits of Mesoneedling may vary, but may include: a possible increase of skin tone, or a possible decrease of wrinkles.
I understand that there are some risks with any procedure. The following is the list of possible risks and side effects of Mesotherapy:

  • Bruising of the skin is very possible.
  • Skin discomfort during the injection.
  • Redness or swelling at the injection site.
  • Itching and bruising lasting 20 minutes to a few hours.
  • Scarring of the skin in exceedingly rare instances.
  • Nausea, dizziness, and possible allergies to Hyaluronidase enzymes may occur.
  • Skin infection is a possibility anytime a surgical procedure is performed.
By my below signature, I acknowledge that I have been informed about the above medications and give consent to its use in my treatment.
I understand that this treatment is strictly for cosmetic purposes. I also understand that I am responsible for all costs payable at the time of service. By my signature, I certify that I have thoroughly read and understand the contents of this form and the disclosures listed above that were made to me.
I agree to pay for the above-mentioned services and understand there will be no refund for any performed
services.
This consent form and cost covers above mentioned treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list.
I have been made award of the risk and I accept these terms and conditions as part of my treatment. My practioner will not accept liability for any of the above side effects.
By signing, I agree to the terms and conditions and in the event of any of the above, I or any of my representatives, will not pursue the practioner in any means of compensation.
  • The objectives and methods of the injection/treatment procedure have been clearly explained to me by the practioner.
  • I have received, read and understood the information supplied by the practioner prior to the injection/treatment.
  • I have had the opportunity to ask any necessary questions.
  • I understand the pre and post injection recommendations and I agree to follow them.
  • I acknowledge that I had the time required for consideration and to make my decision.
  • I acknowledge that I have been clearly informed of the side effects and the rare cases of medical device vigilance.
  • I freely and voluntarily consent to receiving injections/treatment.

I hereby authorise Dr.Homyra JD to treat me. I understand that the effects may not be 100% and that multiple treatments may be necessary to achieve the best results.

I understand that there are certain risks associated with this procedure. I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I fully understand the treatments conditions and procedure.

I agree to pay for the above-mentioned services and understand there will be no refund for any performed services.

This consent form and cost covers above mentioned treatments only. Additional treatments can be added to this consent form and will be charged for as per clinic price list.

I have been made award of the risk and I accept these terms and conditions as part of my treatment. Dr.Homyra JD will not accept liability for any of the above side effects. By signing, I agree to the terms and conditions and in the event of any of the above, I or any of my representatives, will not pursue Dr.Homyra JD in any means of compensation.

The objectives and methods of the injection/treatment procedure have been clearly explained to me by Dr.Homyra JD.

I have received, read and understood the information supplied by the Dr.Homyra JD prior to the injection/treatment. Including all the pages of this document.
I have had the opportunity to ask any necessary questions.
I understand the pre and post injection recommendations and I agree to follow them.
I acknowledge that I had the time required for consideration and to make my decision.
I acknowledge that I have been clearly informed of the side effects and the rare cases of medical device vigilance.
I freely and voluntarily consent to receiving injections/treatment.

DON’T HESITATE TO ASK QUESTIONS IF YOU FEEL THE INFORMATION IS NOT CLEAR. DOCTOR JD WILL BE AVAILABLE TO ANSWER YOUR QUESTIONS. PLEASE, TAKE THE TIME YOU NEED BEFORE MAKING YOUR DECISION!
Client’s Signature [Full Name - E-Signature]
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Date *
FOLLOW-UPS

To ensure the safety of our clients and to achieve optimal results, we use only the highest quality and top-rated products available on the market.  
At Dr JD & Co, we do our best to meet our clients needs, whilst striving for the best and most natural results - each time. Dr JD is an accomplished general practitioner with over 30 years experience and advanced knowledge of the facial anatomy, skin physiology and injecting technique.
It is important to note that for most treatments, the final results show between 2-3 weeks post procedure. Meaning, we encourage you to remain patient during this time, before making final judgement. 
That being said, each body is unique & therefore the biological PH balance and metabolic rate varies between clients. Results cannot be compared, predicted or guaranteed. 
We pride ourselves on our customer satisfaction and will be available to guide and support you during the course of your treatment. 
Should you need any follow-up appointments or questions, please contact Dr.JD’s assistant, who can be reached on: 

Call/Whatsapp  - 0208 881 4667 / 075 13 373 298

Email -  info@drjd.co.uk

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