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STATEMENT OF INFORMED CONSENT FOR INTRALIPOTHERAPY USING SODIUM DEOXYCHLOLATE-BASED SOLUTIONS
Aesthetic medicine often involves complex procedures using advanced medical treatments. Although we at Be Your Aesthetics aim to improve one’s appearance, it is not always guaranteed. In regards to intralipotherapy some factors may affect the final result. These include but are not limited to: diet, exercise, hereditary aspects, hormonal influence, lifestyle and many more.
I accept I understand the above statement and consent that the potential outcome may not always be the desired:
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GENERAL INFORMATION
Localised fat deposits are subcutaneous adipose tissue accumulations in specific anatomical areas that alter body contour. They can be unsightly and unresponsive to a low calorie diet and physical exercise.
Intralipotherapy is a widely used technique in aesthetics medicine. It uses adipocitolytic solutions that contain natural cleansers that cause fat cell lysis (the breakdown of fat.)
The intralipotherapy solution is evenly distributed directly into the fat layer, gradually reducing the size. The treatment can be repeated after a suitable amount of time as explained by your medical practitioner.
The solution is slow acting and the gradual action needs time to achieve the treatment aim. The fat cells in the layer treated with sodium deoxycholate will undergo lysis (cell breakdown) and then a process of degradation and disposal through the lymphatic system.
NON SURGICAL FAT REDUCTION
You must understand this treatment is not an alternative to Diet and Exercise or the Surgical option for removal of Fat.
TREATMENT RISKS
Bruising, bleeding, swelling, redness, infection
Prolonged pain
Allergic reaction (0.002%)
Nodules (0.05%)
Unsatisfactory results (0.3%)
Damage to deep structures (0.01%)
Discolouring (0.002%)
Necrosis of the skin (0.0076%)
Other complications may occur, but these are even rarer.
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I understand the risks associated with Deoxycholate Acid. The procedure has been fully explained to me and I understand in the rare event of a serious complication I may be liable to seek professional opinion from an Emergency Physician or a Plastic Surgeon and Be You Aesthetics Leeds will not be held liable. I understand I will report any complication or adverse reactions to Be You Aesthetics Leeds and understand if needed there may be a reason to be reviewed. I understand that any complications other than listed above may also occur.
I hereby authorise the Nurse/Doctor to carry out this treatment on myself. I understand that I may not achieve the desired outcome and should have realistic expectations and that this has been discussed with your medical practitioner today.
I consent to being photographed before, during and after the intervention for the purpose of clinical documentation. Photos may also be used to promote the product on Be You Aesthetics Social Media Pages only.
I have been informed of all possible complications.
I am aware failure to attend a follow up appointment in the unlikely event of a complication may lead to an even more severe complication.
I confirm I have received extensive information and the practitioner has provided me an opportunity to answer all of my questions.
I understand and will follow all aftercare given to me.
I consent to the processing and communication of my personal data.
I am aware of the Be You Aesthetics Leeds Privacy Policy and understand that personal information may be passed onto a third party when necessary.
