Kybella Consent

(Aesthetics)

Date:

Patient Information

• Patient Name: {{patient_first_name}} {{patient_last_name}}
• Date of Birth: {{patient_birthdate}}

Treatment Information

I understand that I will be receiving Kybella (deoxycholic acid) injections to reduce submental fat (double chin). Kybella is an FDA-approved injectable treatment designed to destroy fat cells in the area under the chin.

Consent Statements

Please initial each statement:

1. I understand the nature of Kybella treatment.

2. I understand the potential risks and benefits.

3. I have been informed of alternative treatments.

4. I understand that results are not guaranteed.

5. I will follow all post-treatment instructions.

Signatures

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.

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Signature Certificate

Kybella Treatment Consent

Unique Document ID: ee780b88dc9a8cf3fcd1d13624c452842f3b7f46

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Timestamp	Audit
December 31, 1969 7:00 pm UTC	Document Uploaded by ENNU - ennu-appointments@ennu.co IP:

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