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.