{"id":58,"date":"2020-07-24T00:54:54","date_gmt":"2020-07-24T04:54:54","guid":{"rendered":"https:\/\/myskincareclub.com\/forms\/?page_id=58"},"modified":"2020-07-25T13:48:47","modified_gmt":"2020-07-25T17:48:47","slug":"client-consent-for-deoxycholic-acid","status":"publish","type":"page","link":"https:\/\/myskincareclub.com\/forms\/client-consent-for-deoxycholic-acid\/","title":{"rendered":"CLIENT CONSENT FOR DEOXYCHOLIC ACID"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"58\" class=\"elementor elementor-58\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3be2c56 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3be2c56\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-4d70933\" data-id=\"4d70933\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f260837 elementor-widget elementor-widget-text-editor\" data-id=\"f260837\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>CLIENT CONSENT FOR DEOXYCHOLIC ACID<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-807cd43 elementor-widget elementor-widget-text-editor\" data-id=\"807cd43\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Deoxycholic acid injections are indicated for improvement in the appearance of moderate to\u00a0<span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">severe convexity of fullness associated with submental fat, also called \u2018double chin\u2019 in adults.\u00a0\u00a0<\/span><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">The safe and effective use of Deoxycholic acid for the treatment of subcutaneous fat outside\u00a0<\/span><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">the submental region has not been established and is off label.<\/span><\/p><p>CONTRAINDICATION: Deoxycholic acid is contraindicated when there is an infection at the\u00a0<span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">injection site. There are no studies on safely during pregnancy or breast feeding. If you are\u00a0<\/span><span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">pregnant or breast feeding then you should not proceed with treatment.<\/span><\/p><p>Initial each statement to accept the risk:\u00a0<\/p><p>RISK: Every injection of any medication involves a certain amount of risk. Below are\u00a0<span style=\"font-size: inherit; text-align: inherit; letter-spacing: -0.015em;\">risks reported during clinical studies that specific to the injection of Deoxycholic acid.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a036aba elementor-widget elementor-widget-wp-widget-frm_show_form\" data-id=\"a036aba\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-frm_show_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_form_widget\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_7_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_clientconsentfordeoxycholicacid\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">CLIENT CONSENT FOR DEOXYCHOLIC ACID<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"7\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_7\" id=\"frm_hide_fields_7\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"clientconsentfordeoxycholicacid\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_7\" name=\"frm_submit_entry_7\" value=\"7304d70deb\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/forms\/wp-json\/wp\/v2\/pages\/58\" \/><div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_inline_container\">\r\n    <label for=\"field_j6zwy\" id=\"field_j6zwy_label\" class=\"frm_primary_label\">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.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_j6zwy\" name=\"item_meta[75]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_inline_container\">\r\n    <label for=\"field_f53xz\" id=\"field_f53xz_label\" class=\"frm_primary_label\">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.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_f53xz\" name=\"item_meta[76]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_inline_container\">\r\n    <label for=\"field_gu405\" id=\"field_gu405_label\" class=\"frm_primary_label\">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.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_gu405\" name=\"item_meta[77]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_inline_container\">\r\n    <label for=\"field_tnv9t\" id=\"field_tnv9t_label\" class=\"frm_primary_label\">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.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_tnv9t\" name=\"item_meta[78]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_inline_container\">\r\n    <label for=\"field_nrb30\" id=\"field_nrb30_label\" class=\"frm_primary_label\">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.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_nrb30\" name=\"item_meta[79]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field  frm_html_container form-field\">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.<br \/>\nI consent to the taking photographs and authorize their anonymous use for the purposeof medial audit, education and promotion.<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_un5ba\" id=\"field_un5ba_label\" class=\"frm_primary_label\">Patient Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_un5ba\" name=\"item_meta[81]\" value=\"\"  style=\"width:40%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_b26dc\" id=\"field_b26dc_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_b26dc\" name=\"item_meta[82]\" value=\"\"  style=\"width:40%\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_s2jye\" id=\"field_s2jye_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad83' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 7.2v-1c0-.3-.2-.5-.5-.5H3.2c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5H7c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm-2 6.2V13c0-.3-.2-.5-.6-.5h-12c-.3 0-.6.2-.6.5v.6c0 .3.3.5.7.5h12c.3 0 .6-.2.6-.5z\"><\/path>\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[83][typed]\" class=\"name\" id=\"field_s2jye\" autocomplete=\"off\" value=\"\"  style=\"width:400px\" maxlength=\"150\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"83\" data-fieldname=\"item_meta[83]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[83][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_236_container\">\n\t\t\t<label for=\"field_6q76o\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_6q76o\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[236]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"xgbTmpRrvI+5BluaOEpLIpzzz5lQ7mSOhKABqz6cwvbq9oXrtQPMpeG4FaMsnd4G\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>CLIENT CONSENT FOR DEOXYCHOLIC ACID Deoxycholic acid injections are indicated for improvement in the appearance of moderate to\u00a0severe convexity of fullness associated with submental fat, also called \u2018double chin\u2019 in adults.\u00a0\u00a0The safe and effective use of Deoxycholic acid for the treatment of subcutaneous fat outside\u00a0the submental region has not been established and is off label. [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-58","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/58","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/comments?post=58"}],"version-history":[{"count":5,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/58\/revisions"}],"predecessor-version":[{"id":103,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/58\/revisions\/103"}],"wp:attachment":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/media?parent=58"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}