You have the right to be informed about your skin condition and treatment so that you may make the decision whether to undergo the procedure, understanding the risks and the hazards involved. This disclosure is not meant to scare you; it is simply an effort to better inform you so that you may give your consent for the treatment program. I know the practice of medicine and surgery is not an exact science,
and, therefore, reputable practitioners cannot guarantee results. No guarantee or assurance has been given by anyone as to the results that may be obtained.
I have requested that one of the providers at Westside Aesthetics attempt to improve the appearance and profile of fat below the chin (submental fat). KYBELLA (deoxycholic acid) is a cytolytic drug indicated for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat in adults. KYBELLA is injected into the fat under the chin.
The most common side effects of KYBELLA include swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. It can also cause tingling, nodules, itching, skin tightness, and headache. These side effects typically resolve without treatment. Other less common but serious potential side effects of KYBELLA include temporary nerve injury in the jaw that can cause an uneven smile of facial muscle weakness, trouble swallowing, superficial skin erosions, small patches of hair loss in the treatment area, or unsatisfactory results.
You should not receive KYBELLA if you have an infection in the treatment area. Inform the physician if you have currently or prior history of dysphagia (difficulty swallowing); have current or prior history of thyromegaly (enlarged thyroid gland); are using anti-coagulants or anti-platelets (i.e. aspirin, warfarin/coumadin, Xarelto, Plavix, etc.); have had or plan to have surgical or aesthetic treatments in or
near the neck area; have had or have medical conditions in or near the neck area; are pregnant, trying to become pregnant or breast feeding.
I have been advised on all the risks involved in such treatment, the expected benefits of such treatment, and the alternative treatments, including no treatment at all. I have informed my physician of my medical conditions including those cautioned above.
I understand that several sessions may be needed for optimal results. I certify that I have read and fully understand the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions. I consent to KYBELLA (deoxycholic acid) injection procedure today and or all subsequent treatments.