Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Email Address*

I am aware that the treatment is carried out by injection and or cannula for the improvement of body contouring.
I consent to receiving the treatment.
I understand the importance of withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I confirm that it is my responsibility to ask sufficient information about the treatment and product.
I understand that the results are permanent depending on lifestyle factors such as diet and additional treatments may be necessary to obtain the desired effect. *

There is likely to be some bleeding, bruising, redness, swelling, stinging, itching, irritation, tenderness and or discomfort at the injection site and the area the product has been placed.
Risks: allergic reaction, infection, scarring, lumps and results may appear uneven.
Post treatment: Avoid anti-inflammatory tablets for 48 hours. Avoid applying product on the treated area for 12 hours. Avoid extreme temperatures, swimming pools/spas/saunas 3days. No exercise 10days. Avoid laser, cryolipolysis or radiofrequency treatments 14days.
I understand that I must adhere to the aftercare advice. *

Aqualyx is for women/men aged between 18 and 60. Not suitable for pregnant women or those who are breastfeeding. Not suitable or for those suffering from lipodystrophy. Hernia. Not recommended for those with a history of severe allergies or a history of anaphylaxis. The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as Aspirin and non-steroidal anti-inflammatories. High doses of Vitamin E and some supplements. *

I understand and acknowledge that payments for the above procedure are non-refundable and due at the time of service.
I further agree in the event of non-payment, to bear the cost of collection and/or Court cost and reasonable legal fees should this be required.
I understand the need for topical anaesthetic may be necessary to reduce the discomfort of the procedure and consent to the application.
I certify that I have read and fully understand the content of this consent form for the procedure and that the disclosures referred to herein were made to me. I am not pregnant and I am not breastfeeding.
I understand and consent to photos for before and after comparisons.
I agree to follow all post treatment instructions carefully and understand that these guidelines are crucial for healing, prevention of side effects and complications.
I have been informed of the risks and benefits of this treatment and wish to proceed with the treatment.
I hereby give consent to carry out the treatment of my choice.
I hereby release the practitioner, the person injecting and the facility from liability associated with this procedure and all future procedures.
I hereby authorise Dolly Patel to administer such treatment to me and agree to hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability. *
Sign Your Name*