Consent Form


I DECLARE that the following points have been explained to me:

mesohyal® is a range of dermal fillers that are administered through intradermal injections. They may be indicated for face and/or body treatments:

  • In face and scalp treatments, mesohyal® is indicated for the correction and treatment of skin aging, fine wrinkles and dermal depressions, scars, skin flaccidity and the devitalisation of scalp tissue. Its high concentration in non-reticulated hyaluronic acid intensely nourishes and moisturises the skin in the treated area and promotes the repair, firming, revitalisation and restructuring of skin tissue.
  • In body treatments, mesohyal® is indicated for reducing fat deposits and capillary permeability while promoting lymphatic drainage. Its high concentration in non-reticulated hyaluronic acid intensely nourishes and moisturises the skin in the treated area and promotes the repair of tissue aged by cellulite, even with excess weight.


mesohyal® is a range of sterile products that must only be used by or under the supervision of clinicians specialised in injection techniques for filling facial wrinkles, intradermal injection or mesotherapy.

mesohyal® is a range of long-term medical devices because it remains in the body for over 30 days where it is subsequently absorbed.

Areas indicated for treatment with mesohyal®: face, neck, neckline, backs of hands, arms, back, abdomen, periumbilical area, thighs, calves, buttocks, saddlebags and scalp.

Contraindications: DO NOT use mesohyal® in the following cases:

  • With laser, chemical peels or dermoabrasive treatments
  • Pregnant or breastfeeding women.
  • Patients with any type of skin disease or alteration.
  • Patients with a history of autoimmune disease or being treated with immunosuppressive drugs or immunotherapy.
  • Patients with hypersensitivity or allergy to any of the ingredients of the product.
  • Patients with acne and/or other inflammatory disease in active stage.
  • Do not apply in areas where permanent fillers or non-absorbent implants already exist.



  • Avoid touching the treated area up to at least 12 hours after treatment.
  • Avoid exposure to sun, UV rays and extreme conditions of heat and cold for at least one week after treatment.


Possible adverse effects:

  • Reactions related to the injection which may persist up to one week: inflammation, mild oedema, erythema, swelling, pain, itching and /or bruising in the injection area.
  • Nodules or hardness in the injection area.
  • Infrequently, necrosis, the formation of abscesses, granuloma and hypersensitivity.


The persistence of any inflammatory reaction for more than one week or the appearance of any other adverse reaction, must be immediately reported to the Clinician, who will provide the suitable treatment and immediately inform the manufacturer.

In addition, I have also been informed of the following aspects:

  • I have been clearly informed of the type and characteristics of the treatment I am going to receive, and the risks and complications which could arise.
  • I also acknowledge that Medicine is not an exact science and that I cannot be given guarantees or absolute safety regarding the results of the treatment.
  • The importance of knowing my personal medical history in terms of allergies to medicines, current medicines, history of facial herpes simplex, personal or family history of keloids or any other circumstance as the occurrence or existence of risks or post-treatment complications are due to personal circumstances, previous health conditions, age, profession, etc.
  • In my personal case, the treatment indicated has been considered to be the most adequate, although other alternatives may exist that would be indicated in other cases and which I’ve had the chance to discuss with the aesthetic professional.


I declare that all the data relating to my medical history are accurate, and that no aspect of interest or about which I have been questioned has been omitted.
Under said conditions, I GIVE MY CONSENT:

  • To Sydney Dermal Lounge and their team to perform the MESOHYAL® mesotherapy treatment by mesoestetic®.
  • I also give my consent to receive any type of additional examinations, modifications or measurements which might be deemed pertinent during the treatment.