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.

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Luis Escobar
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Signature Certificate

Sculptra Treatment Consent

Unique Document ID: 7ce72a0cdddee0e457649e887ee288da9a8487af

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Luis Escobar

Party ID: 897e5ab7-b744-4827-a910-b5c87923ba2a

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Timestamp	Audit
December 31, 1969 7:00 pm UTC	Document Uploaded by ENNU - ennu-appointments@ennu.co IP:
January 29, 2026 3:56 pm EDT	Document sent for signature to Luis Escobar - l_esco@icloud.com

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