Sculptra Treatment Consent

(Aesthetics)

Date:

Patient Information

• Patient Name: {{patient_first_name}} {{patient_last_name}}
• Date of Birth: {{patient_birthdate}}

Treatment Information

I understand that I will be receiving Sculptra (poly-L-lactic acid) injections to restore facial volume by stimulating collagen production. Sculptra is an FDA-approved injectable that gradually replaces lost collagen for results that can last up to two years.

Consent Statements

Please initial each statement:

1. I understand the nature of Sculptra treatment.

2. I understand the potential risks and benefits.

3. I have been informed of alternative treatments.

4. I understand that results are not guaranteed and develop gradually.

5. I will follow all post-treatment instructions.

Signatures

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.

Form Complete