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Kybella Consent Form

A Kybella consent form is a document that patients must sign to confirm that they understand the limits and benefits of Kybella.

Kybella Consent Form

Please read the following information carefully and sign below to indicate your understanding and agreement.

Email*

Patient Information*

Medical History*

Consent*

I understand the risks and benefits of Kybella.

I have had the opportunity to ask questions and have received satisfactory answers.

I have been informed of alternative treatments.

I understand that results may vary and that additional treatments may be necessary.

I understand that there may be side effects and complications.

Patient Signature*

Date*

Select date

Description:A Kybella consent form is a document that patients sign to acknowledge their understanding of the benefits and limitations of Kybella.

Kybella is a non-surgical treatment used to reduce the appearance of submental fullness, commonly known as a double chin. The treatment involves injecting a synthetic form of deoxycholic acid into the targeted area to break down and absorb fat cells. However, like any medical procedure, there are potential risks and side effects that patients must be aware of before undergoing treatment. The Kybella consent form outlines these risks and benefits, as well as any pre- and post-treatment instructions. By signing the form, patients confirm that they have received and understood this information, and give their informed consent to proceed with the treatment.

First Name*

Last Name*

Date of Birth*

Select date

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Date of Birth*

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Date of Birth*

Address*

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Dog's Name*

Dog's Breed*

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