INTRODUCTION: KYBELLA™ (deoxycholic acid) injection is indicated for improvement in the appearance of moderate to severe fullness associated with submental fat, also called “double chin,” in adults. Deoxycholic acid is a bile acid naturally produced by our livers. KYBELLA is a synthetic form of this. The safe and effective use of KYBELLA™ for treatment of subcutaneous fat outside of the submental region has not been established. KYBELLA™ is injected into the fat under the chin. Multiple treatments are required and will be given at least 4-6 weeks apart.

RISKS OF KYBELLA™ INJECTIONS: Every injection of a drug involves a certain amount of risk. Below are risks reported during clinical studies that are specific to the injection of KYBELLA™:
Common potential side effects include: Swelling, Bruising, Pain, Numbness, Redness, Areas of hardness in treatment area, Tingling, Nodules, Itching, Skin tightness, Headache

These side effects typically resolve without treatment and do not usually result in patients stopping treatment.

Less common potential side effects include: Nerve injury—KYBELLA™ injections could cause nerve injury in the area of the jaw resulting in an uneven smile or facial muscle weakness. In the clinical trials these all resolved without treatment in an average of 6 weeks. Swallowing—KYBELLA™ injections can temporarily cause trouble with swallowing (this is thought to be due to neck swelling). Skin Ulceration—KYBELLA™ injections could cause superficial skin erosions. Hair Loss—KYBELLA™ injections could cause small patches of hair loss in the beard area.

Unsatisfactory results: There is a possibility of unsatisfactory results. The procedure may also result in more noticeable platysmal bands, unacceptable visible deformities or asymmetry in the treatment area.

BEFORE RECEIVING KYBELLA™ INJECTIONS: Tell your healthcare provider about all your medical conditions, including if you:

• Have an infection in the treatment area
• Have had or plan to have surgery on the face, neck or chin
• Have had cosmetic treatments on the face, neck, or chin
• Have had or have medical conditions in or near the neck area
• Have trouble swallowing
• Have bleeding problems or are taking blood thinners
• Are pregnant or plan to become pregnant. It is not known if KYBELLA™ will harm an unborn baby.
• Are breastfeeding or plan to breastfeed. It is unknown if KYBELLA™ passes into your breast milk.

Tell your healthcare provider about all medications you currently take, including prescriptions and over-the-counter medicines, vitamins, and herbal supplements. Tell your healthcare provider if you take a medicine that prevents the clotting of blood (antiplatelet or anticoagulant medications such as aspirin, non-steroidal anti-inflammatory medications).

Financial Responsibility

I agree that I am financially responsible for the full payment of service provided. Payment is expected at the time of service. I understand these services are non-refundable and that insurance never covers cosmetic procedures. All other fees are calculated on the actual amount of product used to achieve the desired effect. I also understand that there will be an additional fee for touch ups.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.