Kybella Consent Form

  • Please read completely and sign below.
  • Kybella® is deoxycholic acid, a bile acid that dissolves fat. It is approved for injection into fat under the chin in adults. Injection of other areas is “off label” and not approved by the FDA. Injections may be done monthly until adequate improvement is seen. Kybella® will be injected using sterile precautions and with care and caution to avoid complications, but all procedures carry risks. Minor complications such as temporary swelling, bruising, pain, numbness, firmness, pigment changes, tingling, and itching are common. More unusual complications include nerve or blood vessel injury, scar formation, difficulty swallowing, injury to facial muscles, facial asymmetry, chronic pain and infection. We do not know how the procedure may affect future surgery in the treatment area. Other treatments for this area include plastic surgery, liposuction, and coolsculpting. You should make sure your injecting physician has all your medical information, including past history, current problems, and all medications you take and/or apply. Do not have Kybella® treatment if you are pregnant or have a compromised immune system. Do not have Kybella® treatment if the area has been recently injected or if there is a history of any previous problem in the area, such as prior treatments, implants, or infections.
  • I understand this treatment may not meet my expectations. Although good results are typical, there cannot be a guarantee of results. Kybella® has no proven effect on excess neck skin. After dissolving fat, excess skin may be more prominent.

    I understand there is a possibility of visible deformity or asymmetry or other complication in and around the injected area. These complications may or may not be treatable, and any treatment required would be my responsibility to pursue, including possible corrective plastic surgery. Treatments for potential complications could be expensive and/or cause missed work, and have potential risks as well, including disfigurement, scarring, asymmetry, and infection.

    I understand there may be additional risk and/or consequences which remain unknown at this time.

    I have read and understand all of the information above, and have had opportunity to discuss and ask questions. I accept all of the above mentioned risks of receiving Kybella® and request and authorize Dr. Lisa Gardner or designee to treat me today and on all future occasions.