Hey there!

We just wanted to let you know that any personal information you provide us with is solely for your medical security purposes during your aesthetic procedure, and will not be used for any other purposes.

Also, before we proceed with your treatment, we kindly ask that you confirm that all the information you have provided us with is accurate to the best of your knowledge and that there is no other medical information you need to disclose.

It's important to note that the practice of aesthetic is not an exact science, which means that we can't guarantee the results of your treatment.

However, we do strive for improvement and will work our hardest to achieve the best possible outcome.

So, let's work together to achieve your aesthetic goals!

Health Declaration

Before proceeding with any aesthetic treatments, please read and acknowledge the following:

I have read and understand all questions in this form.
I understand that I am obligated to provide truthful and accurate information.
I understand that the results of aesthetic treatments may vary based on my metabolism, age, gender, ethnicity, and health condition.
I agree to follow all recommendations after treatment.

Full Name

Date of Birth

Full Address

LEMONBOTTLE CELLULITE / FAT DISSOLVE (Lecithin & Bromelain & Vitamin B2)

LEMONBOTTLE is a new injectable compound premium Fat Dissolving product that is different from others on the Korean Lipolysis Market which has a unique blend of active ingredients that not only can destroy the fat cell but can help to excrete it from the body more efficiently.

High- concentration premium LEMONBOTTLE solution combines Riboflavin (vitamin B2) & otherexcellent ingredients to help with fat decomposition which can increase the metabolism of fat cells & canhelp to accelerate it.

Other unique features of Lemonbottle are the tightening effects which can occur in the areas treated & thereduction of cellulite.

It can also facilitate the circulation of the lymphatic fluid & can rapidly release thedegraded fat cells, which is effective in reducing & helping to eliminate cellulite in the area treated.

I understand that combining Lemon Bottle Injections with a balanced diet, adequate water intake, physical activities, and lymphatic drainage massage will ensure more significant results from my treatment.

Composition of Lemonbottle:

Water, Ananas Sativus (Pineapple) Fruit Extract, Pentylene Glycol, Bromelain (phytotherapeutic proteinstem), Sodium Chloride, Lecithin Centella Asiatica Extract (Gotu Kola), Salvia Miltiorrhiza Root Extract,Chamomilla Recutita (Matricaria) Extract, Scutellaria Baicalensis Root Extract, Riboflavin (Vitamin B2)

Do you have any allergies or sensitivities to any products or materials used in aesthetic treatments and Lemon Bottle?

Yes

Composition of Lemonbottle Explained:

Vitamin B2 can induce the activation of fat metabolism, whilst Lecithin helps to destroy & transport the unnecessary fat cells.
The phytotherapeutic protein stem Bromelain is used as an anti-obesity alternative medicine, & it can help to induce apoptosis & lipolysis in mature adipocytes. Bromelain can help to break down fat & remove inflammation.
The secret ingredient is the Riboflavin (B2) that is not generally seen in Lipolysis products but has recently been found that it can drastically increase the degree to which the fat cell is affected, as well as time at which it takes from product administration to when the cell is excreted from the body as waste.
Gotu Kola (Centella Asiatica) help to improve circulation as well as the synthesis of collagen & skin tissue. Collagen is essential for maintaining a taut & youthful complexion. The natural collagen we are born with diminishes as we age (at a rate of about 1% per year). By incorporating the benefits of Centella Asiatica into a Lipolysis product we can help to support the skin’s underlying structure, therefore improving upon loss of firmness.
Centella Asiatica is especially beneficial for improving elasticity. Centella Asiatica is known to help reduce the appearance of cellulite & lose skin

I am voluntarily consenting to Lemon Bottle Fat Dissolve Injections

I also understand that for best results it is advised 3-5 treatments, each treatment every 7-10 days & to drink up to at least 2 litres of water per day throughout the course treatment

I have been informed that treatment can take up to 4 weeks to start to notice any results, although some patients report changes after 24 hours.

I understand that the treatment can cause mild to moderate stinging sensation in the treated area that can last up to 1-4 days.

I need to avoid hot baths and showers, saunas, steam rooms and public pools for 48 hours post treatment

Other side effects include, bruising, swelling, hematomas and slight reddening of the area that may be present for up to 14 days.

I understand that stopping treatment at any time may cause the original symptoms to return.

There is a small risk of infection of the treated skin area after the procedure, although this is not expected to occur due to the sterility of the medical devices used.

The cost of treatment depends upon how big of an area is to be treated & how many vials of product needed to cover the desired area in total. Generally, a small area is from £110 per treatment & a large area is from £180 per treatment but this will be discussed prior to booking.

I acknowledge that no written or implied verbal guarantee, warranty or assurance has been made to me regarding the outcome of the procedure. And I am aware that the Clinician can only work with each person’s individual anatomy & the results are not guaranteed as we are all not biologically identical (even twins) & we all have different host responses to medications, vaccinations & aesthetic treatments as we all have different metabolisms. I understand that individual results may vary, and no guarantees are made regarding the expected outcomes of this procedure. I am happy to proceed with this treatment on this basis.

Treatment is NOT Suitable to Clients with the following Medical Conditions:

Any Allery to any of the components of the product above in composition
Pregnant or breastfeeding
Inability to produce fat (lipodystrophy)
Have an acute or chronic skin disease, skin infection in the affected area or in the skin overlying thetreatment area are not suitable
Clients with pathological conditions (Mycobacterium)
Conditions that affect fat processing in your body
Diabetic patients should avoid treatment as the potential complications of diabetes can complicatetreatment.
Epilepsy
Diseases of the immune system: Clients with autoimmune conditions such as scleroderma should avoid treatment.
Clients with severe liver disease should not be treated as the extra fat it has to process could overworkthe liver.
Clients with severe kidney disease are not suitable for treatment.
Clients on blood thinning medication, in particularly warfarin, will almost certainly not be suitable fortreatment due to the risk of severe bruising.
Blood diseases associated with excessive bleeding
Circulatory diseases
Cancer
Unstabilized thyroid diseases
Heavily Overweight Clients

Do you have any medical conditions or health concerns that may affect your eligibility for aesthetic treatments?

Yes

Fat Dissolve Aftercare:

There may be itching, stinging, redness, or warmth in the treatment area post treatment. This will last between a few hours to a couple of days.
Swelling and bruising are normal and can reside for several days post treatment.
The skin may feel tender to touch.
It is important to massage the area treated & drink plenty of water to help the body remove the excesswaste. We recommend 1-2 litres per day.
Avoid sun exposure or sunbeds for a week post treatment to reduce the chance of hyperpigmentation.
A healthy diet & light exercise should be maintained throughout the course of the treatment.
In rare cases, nodules, necrosis, abscesses, hematomas, or infection may occur. If you experienceanything that concerns you, please seek medical attention immediately.
Pressure garments may need to be worn to enhance the effects of the treatments for short periods oftime.

During recovery, recommend that clients avoid:

Swimming pools, Spas & saunas for 3 days, Heavy Physical exercise for 10 days, Any other aesthetic treatments for 2 week

Can you commit to following the aftercare instructions as outlined above?

Yes

Side effects and risks to be aware of:

Common side effects: Redness, swelling, itchy skin, pain & tenderness in the treated area. Some people experience some lights bruising, but this and any other side effects will usually lasts about 4-6 days

Potential side effects: Flushing, Vagal response (drop-in heart rate / blood pressure), Allergy, Dizziness, Nausea, Necrosis, Abscess, Hyper-pigmentation, Infections, Could cause Sagging of the skin in Treated Area, Hematoma is the most frequent side effect despite all the precautions taken. However it can be easily masked by suitable make-up & can disappear within 4-6 days after the treatment.

I understand that I am undertaking this treatment knowing the full facts, side effects, treatment outcomes and complications and I will not hold the clinic responsible should any issues mentioned above occur. If you experience anything out of the ordinary for you, as you know your own body better than anyone, & you are concerned, then common sense do not hesitate to seek medical attention immediately i.e. 111.

Before & After Photos I give full consent to the use of my before and after images for medical, treatement folloup and marketing purposes. Images will be kept for 6 years and may be used in the event of a claim being brought against us. They will be stored on a password encrypted hard drive. Under GDPR rule I understand that I have full access to all data held on me. This data will be held by the clinic for no longer than 6 years for insurance purposes, after which, digital information will be deleted permanently, and paper documents will be destroyed. All information on myself is kept on password encrypted hard drives or locked in filing cabinets to which only selective staff members have access. None of my personal data will be sold or used for anything other than to provide the services of this clinic.

I agree to the Booking Policy - Terms & ConditionsView terms of Booking Policy

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

If you have suffered a serious side effect, related to the medicine or product used (rather than the technique of the practitioner), you mayreport to The Medicines and Healthcare Regulatory Authority (MHRA) using The Yellow Card Scheme yellowcard.mhra.gov.uk

Terms and conditions

+44 7939055938

Lashes • facial • aesthetics

Hey there!

Health Declaration