Aqualyx Consent

What is Aqualyx? 

Aqualyx™ contains desoxycholan-acid, a secondary bile acid, which the body naturally produces itself in the liver to aid the digestion of fat. The injectable solution is synthesised to dissolve topical fat upon injection into the localised area.

How does it work? 

The human body naturally stores fat to supply energy and subcutaneous fat cells are difficult to diminish. The active substance in Aqualyx locks into the cell wall making it unstable and releasing the fatty acid that is stored within it. Cell residue is removed and broken down by the body’s defences and the released fatty acids are converted to energy. 

What will Aqualyx treatment feel like?

The treatment area will be cleaned, and topical anaesthetic may be applied for comfort. The solution will be injected using a fine and flexible cannula, with minimal injection points (1-4). The area will feel warm and you may experience a slight burning or stinging sensation. 

How long will my results last? 

By following a healthy lifestyle with regular exercise and healthy living the fat should not return in that area. 

How many treatments will I need? 

Number of treatments varies according to the amount of fat and desired result; on average you will be expected to have 3-5 treatments at 3-4 weekly intervals or longer depending on residual swelling and tenderness. 

What areas of the body can be treated? 

Safely administrated to any localised deposit of fat,

Double Chin, waist, saddle bags, chest, jowls, Side of Chin, Hip, knees, inner thighs, upper arms, back buttocks.

What are the possible risks and complications involved? 

Allergic Reaction to the substance Minor haematoma from injection Mild generalised bruising and redness Swelling to area injected Possible injection site infection. 


Are you currently pregnant or breast feeding trying to conceive or IVF treatment?

Do you suffer from any known allergies to drugs, food, etc?

Have you ever been in hospital with a severe allergic reaction?

Do you take any medication?

Have you taken warfarin, ibuprofen, or aspirin in the last ten days?

Have you taken antibiotics in the last two weeks?

Do you take steroids?

Have you taken Isotretinoin or Roaccutane (for acne) in the past 12 months?

Have you had any facial surgery or significant facial injury?

Do you have any permanent implants in your face?

Do you plan to have any dental treatment in the next 2 weeks?

Have you had any IPL or skin peels in the last six weeks?

Have you had COVID-19 symptoms within the last 2 weeks?

Do you currently have COVID-19?

Do you have anxiety or any phobias that may affect treatment? E.g. needles, blood.

Are you prone to fainting, bleeding, bruising, or keloid scaring?

Have you had any sunbed treatment, skin peels, microdermabrasion, or laser in the last 6 weeks?

Do you suffer from any of the following illnesses or diseases? Please tick

What do I need to do after my treatment? 

Do not apply cosmetics to treated area for 12 hours following treatment. Avoid direct sources of heat and sunlight whilst inflamed. Abstain from demanding exercise for 5-7 days. Maintain a healthy diet while released fat is being metabolised to avoid fat storage elsewhere. Drink plenty of fluids following treatment and avoid alcohol/nonsteroidal anti-inflammatory medication or aspirin for 24 hours. 

Contra indications for treatment 

Pregnancy and breast feeding, Severe anaphylactic reactions and allergies Auto-immune disease Diabetics. Acute or chronic skin disease in affected areas Area unsuitable for treatment and Blood thinning medications. Please advise your doctor or Aesthetic Nurse if you have any forthcoming social engagements so a personal evaluation can be made as to any possible downtime associated with the treatment that could impact on your enjoyment of the event. Every individual can react differently to treatment, so it is important to alert your practitioner. 

Everything has been explained to me to for the use of Aqualyx® and I fully understand the possible risks and complications.

I acknowledge and understand that no guarantee or assurance can be made on the results I will get from the treatment.

I hereby request, authorise, and give my consent for the performance of the Aqualyx® treatment. My signature indicates that I have read and understood all the information presented and have had any questions answered. I believe my request for treatment is for medical reasons and the personal psychological features that are associated with my request. I have expressed my thoughts and feelings to the treating and consent to the treatment for the purpose of restoring and maintaining the health of my skin and body and my psychological wellbeing. 

I consent to acting as a model for the purpose of training (under supervision) in the administering of Aqualyx. The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had the opportunity to have all my questions answered to my satisfaction. I have answered the questions regarding my medical history to the best of my knowledge. Training course times may be delayed due to unforeseen circumstances. It may take longer training the students or the student may need more support. So please allow extra time in case this event occurs. Your full payment for your treatment as a model is non-refundable. If the circumstances occur outlined above and/or cancellation your payment is non-refundable. The full payment will be made prior to attending the training academy. Every procedure involves a certain amount of risk and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your practitioner to ensure you understand the risks. Potential complications and consequences of Aqualyx.

I consent to my photographs being stored on a training file and be used for social media purposes.

I consent to Ampika’s Aesthetics using photographs and/or video recordings including images of me both internally and externally to promote the Training Academy. These images could be used in print and digital media formats including print publications, websites, e-marketing, posters banners, advertising, film, social media, teaching and research purposes. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides. I understand that some images or recordings may be kept permanently once they are published. I have read and understand the conditions and consent to my images being used as described. I am signing to consent to my treatment being administered at Ampika’s Aesthetics. On behalf of the training academy Ampika’s Aesthetics - Ampika’s Hair Make Up and Beauty. You are agreeing to be a model and hold no responsibility towards Ampika’s Aesthetics for any procedures that may incur any personal dissatisfaction or cause of concern. 

We are a training academy providing our students with a module in which they facilitate live models in order for each student to get accreditation in the relevant service. 
Medical professionals who observe the students have the right to refuse models who aren’t suitable for a treatment. This would be at their discretion.
We do not support any negative comments on social media or any other rating platforms as you will be refused entry to obtain any further treatments with Ampika’s aesthetics training academy at any one of our locations .

These Students who are responsible for carrying out the treatment under medical supervision, are not fully qualified to carry out Aqualyx unassisted. Therefore, you understand the risk that this may pose. Any concerns must be addressed whilst you are present in the training academy. Whilst all the trainers accommodate you to ensure you are fully satisfied with your treatment, we are unable to rectify problems weeks after you have undergone the treatment. If there are any concerns, then please contact the training academy within 48 hours of treatment via email – [email protected]

Any models wishing to seek any legal or liable action will not be permitted to do so once signing this disclaimer you are excepting full responsibility to allow a student to carry out your injectable treatments.

Vaccination Policy
PLEASE BE AWARE Covid 19 vaccinations like any vaccination such as flu jabs, they can trigger your immune system. This could lead to potential problems with dermal filler treatments and Anti wrinkle injections.

THIS IS EXTREMELY RARE! But we have a duty of care to you to inform you that you must follow our guidelines of:

• Await two weeks after your vaccination to receive any Anti wrinkle injection treatment.
• Dermal Fillers please have your treatment at least TWO WEEKS before your vaccination OR at least three weeks after your vaccination.

The most important point to make is please stay safe and have your VACCINE!

I consent I have read and understood the aftercare sheet which has been provided to me. By signing this form you have agreed to consent to adhere to our vaccination policy.

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Signed by Ampika Pickston
Signed On: June 9, 2021

Signature Certificate
Document name: Aqualyx Consent
lock iconUnique Document ID: 4916797b6fc1cd937deeb020ecf03700f34f4908
Timestamp Audit
November 23, 2020 10:13 am BSTAqualyx Consent Uploaded by Ampika Pickston - [email protected] IP 2a00:23c4:600b:6200:ecb0:e2cc:50f1:3510
February 1, 2021 9:50 am BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:c553:e3b7:94b6:6079
March 24, 2021 2:23 pm BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8
April 21, 2021 9:06 am BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:90f7:ec6:3c7a:16f0
May 17, 2021 2:31 pm BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:8c91:4647:3701:7107