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Sculptra Treatment Consent


Sculptra Treatment Consent

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.

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

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Makenzie Barnes
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Courtney Bell
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Chandra Brenoel
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Chrissy Crutcher
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Chad Perkins
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Luis Escobar
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ENNU Patient Docs
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Shelby Carter
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malloriemmayer@gmail.com
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Karen Bridges
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malloriemmayer@gmail.com
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Lacreta Eskam
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Cindy Clegg
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Rowan Schaefer
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Lee Ann Hamblen
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Laura Johnson
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Caitlin Protenic
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Kathleen Talley
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Emily Burton
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Emily Burton
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Signature Certificate
Document name: Sculptra Treatment Consent
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Courtney Bell
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Chandra Brenoel
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Chrissy Crutcher
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Chad Perkins
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Gina Jacobs
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Amy Whitby
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Emily Burton
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Farida Shadman
Party ID: fc0f94da-c8a1-468c-8f26-72b792850289
Awaiting signature
Timestamp Audit
December 13, 2025 1:56 pm EDTSculptra Treatment Consent Uploaded by ENNU Patient Docs - ennu-appointments@ennu.co IP 139.68.242.135
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