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Congrats on being selected as a model for our upcoming Lipo-dissolve Course

Please read and sign the below consent form.

CONSENT FOR TREATMENT:  Lipo-dissolve (Fat Dissolving Compound) (Deoxycholic Acid Phosphatidylcholine) Compound

Section 1

INTRODUCTION

Deoxycholic acid and phosphatidylcholine injection is indicated for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat, also called “double chin” (in adults) and other small fat pockets on the body. This mixture is injected into the fat (no more than 50 injections or 10 ml under the skin). The injections will be given at least 1 month apart and you may need more than one treatment. Health care providers, in conjunction with the patient, will decide how many treatments are needed. This is an alternative to deooxycholine phosphatidylcholine brand.

Section 2

POSSIBLE RISKS and SIDE EFFECTS

​Every injection of a drug involves a certain amount of risk.  Below are risks reported during clinical studies that are specific to the injections.

  • The injections will commonly cause swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area.  The injections can also cause tingling, nodule itching, skin tightness, and headache.  These side effects typically resolve without treatment and do not commonly result in patients discontinuing treatments.

  • Other less common potential side effects include:

    • Nerve injury: The compound injections could cause nerve injury in the area of the jaw, resulting in an uneven smile or facial muscle weakness. In the clinical trial these all resolved without treatment in an average of 6 weeks.

    • Swallowing: The compound injections can temporarily cause trouble with swallowing during the swelling phase. This resolves near 5 days. 

    • Skin Ulceration: The compound injections could cause superficial skin erosions.

    • Alopecia: The compound injections could cause small patches of alopecia in the treatment area.

    • Unsatisfactory results: There is a possibility of an unsatisfactory result from injections of the compound . The procedure may result in unacceptable visible deformities or asymmetry in the treatment area.

BENEFITS OF COMPOUND INJECTIONS

Deoxycholic acid and phosphatidylcholine injection is indicated for the improvement in the appearance of moderate to severe convexity or fullness associated with fat in adults.

 

BEFORE RECIEVING THE COMPOUND INJECTIONS

Deoxycholic acid and phosphatidylcholine should not be injected if there is an infection in the treatment area.  Before receiving Deoxycholic acid and phosphatidylcholine injections, patients should tell their healthcare provider about all of their medical conditions.  Patients should tell their healthcare provider about all the medications they take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.  They should especially tell their healthcare provider if they take a medication that prevents the clotting of blood (antiplatelet or anticoagulant medicine).

Section 3

By registering, paying and attending the Aestra Institute course, you understand that you may be photographed, filmed or videotaped and you expressly give the Aestra Institute, its owners, agents and principals the right to take pictures and/or recordings of you and use your likeness, image, photo without compensation, for broadcast, display, and exhibition in any medium for purposes of advertisement and education and to put the finished pictures/recordings to any use without limitation. You further expressly release Aestra Institute from any or all claims or actions arising out of or resulting from any use of your image. However, the Aestra Institute shall not be obligated to use your image.


***By consenting to this treatment, I agree, affirm and represent that I am waiving my right to seek any recovery for any damages that occur as a result of receiving this treatment whether such damages are as the result of an inherent risk or latent or unintended risk and including any damages that may occur which are not the result of a known or expected risk. I waive any and all recovery for damages of any kind what so ever.***


I have been informed and I understand that the practitioners who will perform this procedure may or may not be licensed to practice in the state of Florida. I have been informed and understand that Aestra Institute and Denise Merdich have not reviewed or investigated whether the practitioners performing this procedure have appropriate licensure within the state of Florida. Despite knowing that the practitioner(s) performing my procedure may or may not be licensed in Florida, I am voluntarily giving consent for the practitioners who may be licensed in other states to practice medicine, nursing, advanced registered nurse practitioners and physician's assistants to perform the procedure on me. 

Thank you for your consent!

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