11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022
Email: info@cosmomedspaatl.com         Tel: (678) 829-7722

Kybella Consent Form

Kybella is an FDA approved cosmetic injection indicated for improvement in the appearance of submental fullness associated with submental fat in adults. Kybella may be used off label for other areas deemed appropriate by the providers and industry standard.

The results of Kybella are not immediate. At your first treatment visit you will receive a series of injections in the submental area. At the time of injection and for several days following the injections you will have swelling in the submental area. Kybella will cause the fat cells to diminish gradually over the course of the next month 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. Your doctor will decide the appropriate number of treatment sessions and the amount of Kybella you will need at each session.

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.

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 tylenol if you are able to tolerate this medication. Also, you should tell your physician if you take any blood thinners or aspirin or have a history of any issue with lidocaine.

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.
• Avoid heavy exercise the day of your treatment.
• Notify your practitioner if any significant, swelling, bleeding, pain, dusky discoloration, difficulty swallowing or smiling, or fever occurs.

As explained not all submental fullness will respond to Kybella. Other alternative treatments are liposuction to the area, a neck lift and/or platysmoplasty procedures. You agree to have this procedure and understand the full risks & benefits and hold Cosmo Med Spa and its medical providers harmless from any liability associated with you Kybella injections.


THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of all the above noted treatment of Kybella procedures including the risks and dangers inherent therein.
I HEREBY CONSENT to performing the above-noted treatment procedures on me and in consideration of their so doing;
I hereby release and forever discharge Cosmo Med Spa & Salon, from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT)