Kybella Treatment Consent Form

Please read this information carefully and sign to acknowledge your understanding and consent to the Kybella treatment.

About Kybella Treatment

Kybella (deoxycholic acid) is an FDA-approved injectable treatment designed to reduce moderate to severe fat beneath the chin (submental fat), commonly known as a "double chin." The active ingredient is a naturally occurring molecule that aids in the breakdown and absorption of dietary fat.

Treatment Procedure

• Multiple small injections are administered directly into the fat beneath your chin
• Treatment typically takes 15-20 minutes
• Most patients require 2-4 treatment sessions spaced at least 6 weeks apart
• Results are typically visible 4-6 weeks after treatment
• Local anesthesia or ice may be used to minimize discomfort

Potential Side Effects and Risks

Common side effects include:

• Swelling, bruising, pain, numbness, redness, and areas of hardness around the treatment area
• These effects are typically temporary and resolve within 1-2 weeks

Rare but serious side effects may include:

• Nerve injury in the jaw that can cause an uneven smile or facial muscle weakness
• Trouble swallowing
• Injection site alopecia (hair loss)

Terms and Conditions for Kybella Treatment

Treatment Eligibility and Contraindications:

• Patients must be 18 years of age or older
• Treatment is contraindicated in patients with infections in the injection site area
• Not recommended for patients with bleeding disorders or those taking anticoagulant therapy
• Contraindicated in pregnant or nursing women
• Not suitable for patients with dysphagia or other swallowing disorders

Treatment Protocol and Expectations:

• Treatment plan will be customized based on individual assessment and desired outcomes
• Maximum of 6 treatment sessions may be administered
• Minimum 6-week interval required between treatment sessions
• Each treatment session may involve up to 50 injections in the submental area
• Results are not immediate and typically become apparent 4-6 weeks after treatment
• Maximum benefit may not be achieved until 12 weeks after the final treatment

Financial Terms and Payment Policy:

• Payment is due at the time of service unless other arrangements have been made
• Treatment costs are not covered by insurance as this is considered a cosmetic procedure
• No refunds will be provided after treatment has been administered
• Additional treatments beyond the initial plan may incur additional charges
• Prices are subject to change with 30 days written notice

Appointment and Cancellation Policy:

• Appointments must be cancelled at least 24 hours in advance
• Late cancellations or no-shows may result in a cancellation fee
• Follow-up appointments are mandatory and must be scheduled as directed
• Failure to attend follow-up appointments may affect treatment outcomes

Results and Limitations:

• Results vary significantly between individuals
• No guarantee of specific outcomes or degree of improvement
• Some patients may not respond to treatment
• Additional treatments may be necessary to achieve desired results
• Results may diminish over time due to natural aging process
• Weight gain may affect treatment results

Informed Consent and Risk Acknowledgment:

• Patient acknowledges receiving comprehensive information about the procedure
• All questions regarding treatment have been answered to patient's satisfaction
• Patient understands this is an elective cosmetic procedure
• Alternative treatment options have been discussed
• Patient voluntarily consents to treatment with full understanding of risks

Photography and Documentation:

• Pre and post-treatment photographs may be taken for medical records
• Photos are used for treatment planning and outcome assessment
• Patient consent required for use of photos for educational or marketing purposes
• All medical records and photos are confidential and HIPAA protected

Follow-up Care and Responsibility:

• Patient is responsible for following all pre and post-treatment instructions
• Must report any adverse reactions immediately
• Attend all scheduled follow-up appointments
• Comply with recommended aftercare protocols
• Inform provider of any changes in medical status or medications

Limitation of Liability:

• Treatment is provided in accordance with accepted medical standards
• No warranty or guarantee of results is provided
• Patient assumes responsibility for compliance with aftercare instructions
• Provider liability is limited to the cost of the treatment provided

Regulatory and Safety Information:

• Kybella is FDA-approved for submental fat reduction in adults
• Treatment is performed by licensed medical professionals
• Facility maintains appropriate medical emergency protocols
• All adverse events will be reported as required by FDA guidelines

Post-Treatment Care Instructions

Immediately after treatment (first 24-48 hours):

• Apply ice packs for 10-15 minutes every few hours to reduce swelling
• Keep head elevated when sleeping for the first few nights
• Avoid strenuous exercise for 24-48 hours
• Take over-the-counter pain medication as needed

First week after treatment:

• Gentle massage of the treated area as directed
• Avoid excessive heat (saunas, hot tubs, direct sunlight)
• Continue to sleep with head elevated
• Avoid alcohol consumption for 24 hours

Ongoing care:

• Attend all scheduled follow-up appointments
• Contact our office immediately if you experience severe pain, difficulty swallowing, or signs of infection
• Results will gradually appear over 4-6 weeks
• Maintain a healthy lifestyle to preserve results

When to contact us:

• Severe or worsening pain
• Signs of infection (fever, excessive redness, warmth, pus)
• Difficulty swallowing or speaking
• Numbness that persists beyond 2 weeks
• Any other concerning symptoms