top of page

Aqualyx Consent Form

Birthday
Day
Month
Year

Aqualyx® is a fat-dissolving injectable treatment used to reduce stubborn pockets of fat that are resistant to diet and exercise. It contains deoxycholic acid, a bile-derived compound that breaks down fat cell membranes. The body then naturally removes the destroyed fat cells via the lymphatic system over a period of weeks.

Aqualyx is suitable for areas such as:

  • Chin (submental area)

  • Jowls

  • Abdomen

  • Flanks (“love handles”)

  • Inner thighs or knees

  • Upper arms

  • Bra fat or back fat

  • Small pockets around the armpits or under the buttocks

A course of 2–6 sessions spaced 4–6 weeks apart may be required, depending on the treatment area and individual response.


Contraindications


Aqualyx® should not be administered if you:

  • Are pregnant or breastfeeding

  • Are under 18 years of age

  • Have known allergies to deoxycholic acid or any component of the solution

  • Have active skin infections, rashes, or inflammation at the treatment site

  • Have uncontrolled diabetes or thyroid dysfunction

  • Have severe liver or kidney disease

  • Have autoimmune conditions or are immunosuppressed

  • Have bleeding disorders or are taking anticoagulant medication

  • Have lipodystrophy or significant loose skin in the area to be treated

Please ensure your full medical history and medications have been disclosed.


Risks and Side Effects


Common temporary side effects include:

  • Swelling, redness, and tenderness (especially for 3–10 days post-treatment)

  • Bruising

  • A stinging or burning sensation at the injection site

  • Firmness or nodules under the skin during the healing phase

  • Itching or mild irritation

  • Temporary numbness


Less common but possible side effects:


  • Infection

  • Prolonged inflammation or hard lumps

  • Uneven fat removal or contour irregularities

  • Skin discolouration (temporary or permanent)

  • Scar tissue formation or poor wound healing in rare cases

  • Allergic reaction or anaphylaxis (extremely rare)

Treatment is generally safe when administered by a qualified professional following proper protocols.


Aftercare Instructions


To minimise complications and improve results:

  1. Avoid touching or massaging the treated area for at least 12 hours

  2. Do not apply makeup or fragranced products to the area for 24 hours

  3. Avoid alcohol, strenuous exercise, hot showers, steam rooms, and saunas for 48–72 hours

  4. Apply cool compresses (not ice) for swelling if advised

  5. Avoid tight clothing around the area

  6. Keep hydrated and maintain a healthy lifestyle to support fat elimination

  7. Mild pain or swelling may be managed with paracetamol (avoid ibuprofen or aspirin unless advised)

It may take 4–6 weeks to start seeing results, and treated areas may feel firmer or tender for some time.


Treatment Expectations


  • Aqualyx is not a weight-loss solution and is best suited for localised fat reduction

  • It does not tighten loose skin or treat cellulite

  • Results are gradual, and multiple sessions may be needed

  • Final outcomes depend on lifestyle, metabolism, area treated, and individual response


Consent Declaration


By signing this form, I confirm that:

  • I have received a full explanation of the Aqualyx treatment, including procedure, risks, benefits, side effects, and aftercare

  • I have disclosed all relevant medical history, allergies, and medications to the best of my knowledge

  • I understand that results are not guaranteed and can vary between individuals

  • I have had the opportunity to ask questions, and they have been answered to my satisfaction

  • I am not pregnant or breastfeeding

  • I understand the importance of aftercare and attending follow-up treatments if recommended

  • I voluntarily consent to undergo Aqualyx fat-dissolving treatment administered by a qualified medical professional

 

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

ADDRESS

1a Piermont Place 
Dawlish 
Devon 
EX7 9PQ

CONTACT

Tel: 07738287979

Email: mel@themodernmuse.co.uk

OPENING HOURS

Mon, Fri & Sat: flexible hours

FORMS

© 2025 by The Modern Muse

bottom of page