I have read and understand this document entitled: Informed Consent for Injection of Kybella

I hereby authorize Timeless Beauty Aesthetics, to perform the following procedure: Injection of Kybella.

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

I will follow all aftercare instructions as it is crucial to do so for good healing and to minimize the risk of complications.

For purposes of advancing medical education, I consent to the admittance of observers to the treatment room.

Kybella is an FDA approved cosmetic injection indicated for improvement in the
appearance of submental fullness associated with submental fat in adults (double chin).
All other areas that are treated with Kybella are OFF LABEL- this means they have not
been approved by the FDA. However we have had great success with other areas and
physicians are currently collecting data to submit to the FDA in order to get other areas
approved.
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The results of Kybella are not immediate. At your first treatment visit you will receive a series of injections in the area you wish treated. At the time of injection and for several days following the injections you will have swelling in the area. Kybella will cause the fat cells to diminish gradually over the course of the next several months 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.

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.
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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 Dr. Happe if
you take any blood thinners or aspirin or have a history of any issue with lidocaine or
epinephrine.
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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 your provider if any significant, swelling, bleeding, pain, dusky discoloration,
difficulty
swallowing or smiling, or fever occurs.

I grant permission and consent to Timeless Beauty Aesthetics for the use of the following photograph(s) as identified below for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

It has been explained to me in a way that I understand:

1. The above treatment or procedure to be undertaken.

2. There may be alternative procedures or methods or treatment.

3. There are risks, known and unknown, to the procedure or treatment proposed.