I have had ample opportunity to discuss these issues, and all questions have been answered to my satisfaction. I understand that there are other alternative treatments that I could undergo, and I elect to receive the KYBELLA injection(s).
I accept all of the above-mentioned risks of receiving the KYBELLA treatment and request and authorize my provider at Infuze Wellness Center to treat me.
The practice of medicine and surgery is not an exact science. Although good results are expected, there cannot be any guarantee, or warranty, expressed or implied, by anyone as to the results that may be obtained.
I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS WITHIN THE ABOVE CONSENT AND THE EXPLANATION MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING COMPLETION WERE FILLED IN AND ANY APPLICABALE PARAGRAPHS WERE STRICKEN BEFORE I SIGNED. I ALSO STATE I SPEAK, READ AND WRITE ENGLISH.