Injectable Fat Dissolving Consultation

For Lemon Bottle and Aqualyx. Please complete the form honestly before your appointment.

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Fat dissolving online form

Client details and suitability

Do not fill this out:

Full name Date of birth Contact number Email address Address How did you hear about us?

Product selection Lemon Bottle Aqualyx Not sure - please advise

Area(s) to be treated Double Chin / Jawline Abdomen / Tummy Love Handles / Waist Bum / Hips Inner Thighs Outer Thighs Back / Bra Line Upper Arms / Bingo Wings Other

Main concern / what would you like to improve? Ideal result Have you had fat dissolving injections or similar treatments before? If yes, please give details Have you had surgery, liposuction or injury in the treatment area in the last 12 months? Are you currently following a diet or exercise programme?

Medical history

Please answer Yes or No. This helps the clinic check whether treatment is safe and suitable.

Do you have poor circulation, blood clots or history of DVT?Do you have diabetes, heart conditions, high or low blood pressure?Do you have any autoimmune conditions or immune system disorders?Do you have liver or kidney disease / reduced liver or kidney function?Do you have any skin infections, open wounds, eczema, psoriasis or scars in the treatment area?Do you have a history of keloid scarring or abnormal healing?Are you pregnant, breastfeeding or planning to become pregnant?Do you have allergies, especially to soya, phosphatidylcholine, deoxycholic acid or product ingredients?Are you allergic to local anaesthetic / lidocaine?Do you suffer from nerve conditions or numbness in the area to be treated?Have you had any vaccination in the face/body area within the last 2 weeks?Do you smoke or drink alcohol regularly?Are you taking any medication, supplements or anti-inflammatory drugs? Please list any other health issues or details we should know I confirm that I have read and understood the treatment information, possible risks, expected results and aftercare guidance. I confirm the information provided is true and I consent to Angel Hands Aesthetics reviewing this consultation form.

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Angel Hands AestheticsPrivate appointment-only clinic • Dulwich