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Fat Dissolving Injection Consent Form and Medical History
溶脂针疗程同意书

Patient Information 个人信息

Medical History 医疗历史

Procedure Understanding. I understand that Fat Dissolving Injections involve a series of injections into the subcutaneous fat layer to break down local fat deposits. The most common active ingredients are Deoxycholic Acid or similar compounds. I understand that:

  • This treatment is intended for localised contouring and is not a substitute for weight loss or a treatment for obesity.

  • Results are typically visible 4–8 weeks after treatment.

  • A series of treatments (typically 2–4 sessions) may be required to achieve the desired effect.


Risks and Potential Side Effects. I understand that fat-dissolving treatments involve an inflammatory process. Potential side effects include:

  • Common Reactions: Significant swelling (edema), redness, bruising, tenderness, and heat at the injection site. Swelling can be pronounced and may last for 7–14 days.

  • Numbness & Hardness: Temporary numbness or a feeling of "hardness" (induration) under the skin at the treatment area is common and usually resolves as the fat is metabolized.

  • Nerve Injury: In rare cases, injections near the jawline may cause temporary nerve injury, leading to an uneven smile or facial muscle weakness.

  • Skin Irregularities: Possible risks include skin laxity, uneven contour, or nodules (small lumps) at the injection site.

  • Rare Risks: Skin ulceration, tissue necrosis, or allergic reactions to the ingredients.


Client Acknowledgement and Consent. I confirm I am not pregnant or breastfeeding and do not have active infections or skin diseases in the treatment area.

  • I have disclosed all medical conditions, including liver or kidney disease or blood clotting disorders.

  • I understand that fat cells are permanently destroyed, but remaining fat cells can still expand if I gain weight.

I certify that I have read this document and understand the risks, benefits, and costs. I have been given the opportunity to ask questions, and they have been answered to my satisfaction.


治疗程序知情

本人理解,溶脂针是通过向皮下脂肪层进行一系列注射,以分解局部堆积的脂肪。最常用的成分是脱氧胆酸或类似化合物。本人知悉:

  • 本治疗旨在进行局部塑形,不能替代减重,亦非肥胖症的治疗手段。

  • 治疗效果通常在术后 4-8 周显现。

  • 通常需要多次治疗(一般为 2-4 次)方可达到理想效果。


风险与潜在副作用

本人理解溶脂治疗涉及炎症反应过程。潜在副作用包括:

  • 常见反应: 注射部位出现明显的肿胀、发红、淤青、触痛及发热感。肿胀可能较为显著,通常持续 7-14 天。

  • 麻木与硬结: 治疗区域出现暂时性麻木或皮下“发硬”感是常见现象,通常随脂肪代谢而消失。

  • 神经损伤: 在极少数情况下,当下颌缘附近注射时,可能导致暂时性神经损伤,引起笑容不对称或面部肌无力。

  • 皮肤不平整: 潜在风险包括皮肤松弛、轮廓不平整或注射部位出现结节(小肿块)。

  • 罕见风险: 皮肤溃疡、组织坏死或对药物成分产生过敏反应。


客户确认与同意

  • 本人确认未处于妊娠期或哺乳期,治疗区域无活跃期感染或皮肤病。

  • 本人已如实告知所有医疗状况,包括肝肾疾病或凝血功能障碍。

  • 本人理解脂肪细胞已被永久破坏,但若体重增加,剩余的脂肪细胞仍可能肥大。

本人确认已阅读本文件并理解相关风险、益处及费用。本人已获得充分提问机会,所有问题均得到满意解答。

Consent Form 同意书

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已選擇繪畫模式。請使用滑鼠或觸控板。如要使用鍵盤,請選擇「文字輸入」或「上傳」。
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