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Consent Form

Please complete this consent form before your Lemon Bottle Fat Dissolving Injections appointment. Once you sign, a copy is emailed to you and to Gemma automatically.

Your details

Lemon Bottle Fat Dissolving Injections — treatment information & disclaimer

Lemon Bottle fat dissolving is an injectable treatment used to target and break down small, stubborn pockets of fat. It is administered by injection into the treatment area. A course of treatments is usually required and results vary between individuals with no guarantee of a specific outcome. It is not a treatment for weight loss.

Common side effects include swelling (which can be significant for several days), redness, tenderness, bruising, warmth and itching at the treated area. Uncommon risks include infection, firm lumps or nodules, and numbness.

Rare risks include allergic reaction and, very rarely, injection into a blood vessel. Please tell your practitioner immediately if you feel unwell. You must follow all pre- and post-treatment advice, and disclose any medical condition, medication or allergy before treatment.

A non-refundable deposit is required to secure your appointment. The balance is payable at your appointment. Deposits and booking fees are non-refundable unless agreed with the practitioner.

Medical screening

Please answer honestly — this keeps your treatment safe. Add detail in the notes where relevant.

1. Are you pregnant, breastfeeding, or trying to get pregnant?
2. Do you have any medical conditions? If yes, please give details.
3. Are you taking any medication (including blood thinners such as Warfarin/Aspirin)? If yes, please list.
4. Do you have any allergies, or have you ever had anaphylaxis? If yes, please give details.
5. Do you have any skin or neuromuscular disorders?
6. Do you have diabetes, an autoimmune disease, or a bleeding/clotting disorder?
7. Do you have a history of keloid or hypertrophic (raised) scarring?
8. Do you have any active infection, cold sores, or inflammation at the treatment area?
9. Have you had this or a similar treatment before? If so, did you have any problems?
10. What are your aims and motivations for the treatment / desired outcome? Please give details.
11. Is there any other medical or social history we should know? Please give full details.
12. Do you understand the information provided and feel it is sufficient for you to consent?
13. Has your consent been given freely?

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