Kybella Consent Form PDF Details

Kybella is an FDA-approved cosmetic treatment that helps improve the appearance of submental fullness or a double chin by reducing submental fat in adults. This consent form outlines the details of the procedure, potential side effects, pre and post-care instructions, alternatives to Kybella, and authorizations for medical personnel to perform the treatment.

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Form NameKybella Consent Form
Form Length2 pages
Fillable fields6
Avg. time to fill out1 min 42 sec
Other nameskybella consent forms, consent form for kybella from allergan, allergan consent forms, consent form for kybella

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Kybella® Injection Consent

Kybella® is an FDA approved cosmetic injection indicated for improvement in the appearance of submental fullness associated with submental fat in adults.

The results of Kybella® are not immediate. At your first treatment visit you will receive a series of injections in the submental area. At the time of injection and for several days following the injections you will have swelling in the submental area. Kybella® will cause the fat cells to diminish gradually over the course of the next month following your injection in the treated area. A series of treatments may be necessary to achieve optimal results and these will occur at no sooner than the one-month interval. Your doctor will decide the appropriate number of treatment sessions and the amount of Kybella® you will need at each session.

Side Effects:

Side effects of Kybella® may include: bruising, swelling, numbness, induration, marginal mandibular nerve injury, dysphagia (difficulty swallowing), bleeding, tenderness or discomfort, tissue necrosis, hyperpigmentation, redness, or alopecia at the site of injection.

Alopecia: Kybella® injections could cause small patches of alopecia in the treatment area. Pre- Instructions:

You should not be pregnant, nursing an infant, have a history of a bleeding disorder or infection of the area to be treated. The morning of your treatment you should take ibuprofen if you are able to tolerate this medication. Also, you should tell you physician if you take any blood thinners or aspirin or have a history of any issue with lidocaine or epinephrine.

Post Care Instructions:

Ice packs may be used to the treated area during the first 12 hours – ice for 15 minutes on every hour

Do not massage the injection site

If you are able to tolerate ibuprofen, take 200mg three times daily beginning the day of your treatment and for the following four days

Avoid heavy exercise the day of your treatment

Notify us if any significant, swelling, bleeding, pain, dusky discoloration, difficulty swallowing or smiling, or fever occurs.


As explained not all submental fullness will respond to Kybella®. Other alternative treatments are liposuction to the area, a neck lift and/or platysmoplasty procedures.

The medical director will review all treatments planned for clients. The safety of all procedures are outlined in the protocols manual on site. The well-planned protocols establish safety and allow delegation to the RN to perform.

I hereby authorize ________________________________, delegated staff, and such assistants as may

be selected to perform the following procedure or treatment:

Deoxycholic acid injection injections with Kybella® for improvement in the appearance of moderate to severe convexity or fullness associated with submental (neck) fat.

I recognize that during the course of the injectable treatment, unforeseen conditions may necessitate different procedures than those above. I therefore authorize the above physician or affiliated medical personnel or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my physician at the time the procedure is begun.

I consent to the administration of such anesthetics considered necessary or advisable. I understand that all forms of anesthetics involve risk and the possibility of complications, injury, and sometimes death.

I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.

For purposes of advancing medical education, I consent to the admittance of observers to my aesthetic injectables.

I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical-device registration, if applicable.



I certify that I have read all pages of this document and give my consent for my injectable procedure.



Patient Signature / Date

Witness Signature / Date



Print Patient Name

Print Witness Name

I certify that I have explained the nature, purpose, benefits, risks, complications, and alternatives to the proposed procedure to the patient. I have answered all questions fully, and I believe that the patient fully understands what I have explained.


Provider Signature / Date

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Type in the appropriate information in the box I certify that I have read all, Patient Signature Date, Witness Signature Date, Print Patient Name, Print Witness Name, I certify that I have explained, and Provider Signature Date.

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