DEOXYCHOLIC ACID INFORMED CONSENT

Deoxycholic acid (PCDC) is a prescription-strength injection used to treat the double chin (submental fat) in adults. PCDC destroys the fat cells that accumulate in the neck. The body then naturally eliminates the fat slowly over a few weeks. Once these cells are destroyed, they can no longer store or accumulate fat. PCDC is prepared in a very controlled solution and then injected into the skin with a very fine needle. Patients may feel a burning sensation while the solution is being injected. The treatment takes about 15 - 20 minutes. Most patients require two vials per treatment and require two to four treatments. Some patients require up to six treatments depending on the amount of fat or until the desired effect is achieved. Final improvement is assessed twelve weeks after the final treatment.

Risks and Complications

This list is not meant to be inclusive of all possible risks and complications associated with PCDC as there are both known and unknown side effects associated with any medication or procedure. The possible side effects of PCDC include but are not limited to:

1. Swelling (edema) in the treatment area (always)
2. Bruising (hematoma) in the treatment area
3. Pain in the treatment area
4. Numbness in the treatment area
5. Redness (erythema)
6. Areas of hardness (induration) in the treatment area
7. Ulceration of the skin in treatment area
8. Temporary or permanent hair loss at the injection site(s)
9. Less common side effects include, but are not limited to, tingling, nodules, itching, skin tightness, and headache. These side effects typically resolve without treatment.
10. Other less common but serious potential side effects of PCDC include temporary nerve injury in the jaw that can cause an uneven smile or facial muscle weakness, trouble swallowing, superficial skin erosions, small patches of hair loss in the treatment area, or unsatisfactory results.

Alternatives

PCDC is best used in treatment of the double chin (submental fat. Alternative treatments for a double chin include surgical treatments such as a facelift or neck lift, liposuction, and non-surgical treatments such as energy-based devices.

Contraindications

PCDC treatments should not be performed on anyone who has an infection in the area. PCDC has not been studied on women who are pregnant, trying to become pregnant, or breast feeding. PCDC treatments are not recommended for those with medical conditions in the neck area including, but not limited to, difficulty swallowing, those that are planning to have cosmetic surgical treatments in the neck or face area such as a facelift or neck lift, those with an enlarged thyroid gland (thyromegaly), or those with a bleeding disorder.

Results

The number of vials and treatments is an estimate of the amount of PCDC required to address double chin (submental fat). There is no guarantee of results for any treatment and up to six treatments may be needed to achieve a satisfactory result. Follow-up is recommended six weeks after treatment.

Consent

I acknowledge that I have read the foregoing informed consent, I understand it, and I agree with the treatment with its associated risks and complications. The treatment has been explained to me, and my questions have been answered satisfactorily. I understand that this is an elective procedure. I understand that I will be injected with PCDC in the area of the double chin (submental fat) with the goal of improving the appearance of the double chin (submental fat). I understand that the number of vials and treatments required is an estimate of the amount of PCDC required to improve the appearance of the double chin (submental fat) and that there is no guarantee of results of any treatment. I acknowledge that I am not pregnant, possibly pregnant, trying to become pregnant, or breast feeding. I acknowledge that I do not have an infection in the area to be treated. I acknowledge that I do not have a medical condition(s) in the neck area including, but not limited to, difficulty swallowing. I acknowledge that I am not planning to have cosmetic surgical treatments in the neck or face area such as a facelift or neck lift. I acknowledge that I do not have an enlarged thyroid gland (thyromegaly). I acknowledge that I do not have a bleeding disorder.

I certify that if I have any change in my medical history, I will notify Top Beauty Bar immediately. I authorize clinical photographs to be taken for my medical record. I will follow all aftercare instructions as it is crucial I do so for healing. I hereby voluntarily consent to the current and subsequent PCDC treatments with the above understood. I hereby release the person injecting PCDC and Top Beauty Bar from liability associated with this treatment.

I have read, and acknowledge these requirements of the procedure. 

Medical Waiver

I have read, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if a protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily I understand this procedure and accept all risks and will notify Top Beauty Bar of any changes that could put my treatment at risk.

I take full liability and responsibility for all risks, undesired outcomes, or adverse events associated with the injections and will not hold the provider of Top Beauty Bar LLC liable for any unfavorable outcome or adverse event. I release Top Beauty Bar LLC, its owner, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I hereby release Top Beauty Bar LLC, Tina Videtic, and staff from all liabilities associated with the indicated procedure. The procedures to be used to treat my condition have been explained to me. Any adverse reaction should be reported immediately to the office mobile at 920-678-7709.

I have read, and acknowledge these liability requirements of my procedure.