CLIENT CONSENT FOR DEOXYCHOLIC ACID

Deoxycholic acid injections are indicated for improvement in the appearance of moderate to severe convexity of fullness associated with submental fat, also called ‘double chin’ in adults. The safe and effective use of Deoxycholic acid for the treatment of subcutaneous fat outside the submental region has not been established and is off label.

CONTRAINDICATION: Deoxycholic acid is contraindicated when there is an infection at the injection site. There are no studies on safely during pregnancy or breast feeding. If you are pregnant or breast feeding then you should not proceed with treatment.

Initial each statement to accept the risk:

RISK: Every injection of any medication involves a certain amount of risk. Below are risks reported during clinical studies that specific to the injection of Deoxycholic acid.

Deoxycholic acid injections commonly cause swelling (87%), bruising (72%), pain (70%), numbness (66%), redness (27%), and areas of hardness in the treatment area (23%). Deoxycholic acid injections may also cause tingling, nodule, itching, skin tightness, and headache. These side effects typically resolve without treatment and do not commonly result in patients discontinuing treatment.

Other less common potential side effects include: Nerve injury: Deoxycholic acid injections may cause nerve injury in the area of the jaw resulting in an uneven smile or facial muscle weakness (4%). In clinical trails, these all resolved without treatment in an average of 6 weeks.

Swallowing: Deoxycholic acid injections may temporarily cause trouble swallowing (2%) Skin Ulceration: Deoxycholic acid injections may cause superficial skin erosions. Alopecia: Deoxycholic acid may cause all patches of hair loss in treatment area.

Unsatisfactory Results: There is a possibility of any unsatisfactory result from injections of Deoxycholic acid. The procedure may result in unacceptable visible deformities, such as asymmetry in the treatment area and prominence of platysmal (neck muscle) bands.

Redundant Skin: Increase laxity (looseness) of the neck skin as not observed in clinical trails, however the possibility exists whenever fat is removed. Incomplete Fat Removal: Approximately (50%) of neck fat is below the muscle. Deoxycholic acid injections do not target this fat, and residual fullness may remain. I consent to the taking of photographs and authorize their anonymous use for the purpose of medical audits, education and promotion.

I have requested treatment with Deoxycholic acid. The side effects and risk associate with this treatment been explained to me. I have been told about the potential benefits of treatment, and alternative treatment, including no treatment at all. I understand clinical trails show multiple treatments are necessary to produce permanent results, and that increase in body weight may diminish the effects of treatment. I have read and fully understand this consent form. I have been able to ask questions about treatment and all of my questions have been answered to my satisfaction. I hereby consent to treatment with Deoxycholic acid.
I consent to the taking photographs and authorize their anonymous use for the purposeof medial audit, education and promotion.

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