MESOTHERAPY
Title (Mr, Mrs, Miss, Ms): ___________
First name: _____________________ Surname: _________________________
Address: ___________________________________________________________
___________________________________________________________
Post Code: _____________________
Date of birth: ____________________ Age: ____________________________
Tel - Daytime: ____________________ Tel - Evening: _____________________
Mobile: _________________________
Next of Kin - Name & Surname: ________________________________________
Address: __________________________________________________________
Tel: ___________________________ Mobile: ___________________________
GP Name: _________________________________________________________
Address: __________________________________________________________
Post Code: _____________________ Telephone: ________________________
CONSULTATION FORM
Age: □ 18 - 20 years □ 21 - 30 years □ 31 - 40 years □ 41 - 50 years □ 51 and over
What promted you to book Mesotherapy?
__________________________________________________________________
What are you using to treat your cellulite at the moment?
__________________________________________________________________
Are you on weight loss programme? If yes, please specify:
__________________________________________________________________
__________________________________________________________________
What is your weekly consumption of alcohol? ______________________________
Do you smoke? If so, how many? ________________________________________
Do you take any vitamin, mineral or herbal supplements? Please specify:
___________________________________________________________________
Do you have an exercise regime? If yes, please specify: ______________________
___________________________________________________________________
How would you best describe your lifestyle?
□ Relaxed
□ Stressful
How would you describe the activity rating of your occupation?
□ Very active □ Active
□ Hectic
□ Sedentary
Are you taking any forms of contraceptives of HRT?
□ No □ Yes, please specify: _____________________________
Are you on any type of medication?
□ No □ Yes, please specify: ______________________________
Do you have any type of injury or operation in last 12 months?
□ No □ Yes, please specify: ______________________________
Allergies - please state any allergies or reactions to drugs, plasters etc.:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
______________________________________________________________________
CONTRAINDICATION TO MESOTHERAPY TREATMENT
ABSOLUTE
 Hyperthyroid
 Allergy to iodine
 Heart conditions
 Pacemaker
 Renal and liver disorder
 Less than 6 weeks post natal
 Pregnant & planning pregnancy
 Breastfeeding
 Thrombosis
POSSIBLE




Diabetes (insulin controlled)
Epilepsy (on medication)
Drugs causing skin sensitivity
Skin diseases and allergies
I have read and understand the contraindications.
Signed: __________________________
Date: ___________________
PATIENT CONSENT
I declare that the information that I have given is true and correct and as far as I am aware
I can undertake Mesotherapy treatment without any adverse effects.
Some patients may experience pain at the site of the injection, redness, slight tingling and
treated area of warmth. Bruising in all patients cleared up within 7 - 14 days of completing
treatment.
I understand that the results of Mesotherapy are individual. Thus no guarantee can be made
as to the results of my treatment.
I understand that I am responsible for all costs at the time of service.
I will follow all aftercare instructions.
By my signature, I certify that I have thoroughly read and understand the contents of this
form.
Patient’s signature: ________________________
Date: _____________________
TREATMENT RECORD FORM
Prior to treatment:
Blood pressure:
Pulse:
Weight:
AREAS TO BE TREATED
TREATMENTS:
Meso medication:
 L-Carnitina (5ml)
 Lipoliticas (5ml)
 Procaine (5ml)
 Silico-Organico
(5ml)
 Triac (5ml)
Treatment
number
Treatment date
Number of
ampoules
Comments: ________________________________________________________________
__________________________________________________________________________