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.

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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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Kathleen Talley
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Kristen Cook
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Gina Jacobs
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Amy Whitby
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Emily Burton
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Farida Shadman
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Emily Burton
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Farida Shadman
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Emily Burton
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Farida Shadman
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Emily Burton
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Farida Shadman
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Signature Certificate
Document name: Sculptra Treatment Consent
lock iconUnique Document ID: 539f09adf61da5eb230cf50897f408017a874c10
Makenzie Barnes
Party ID: ae670515-207f-4134-afde-f6edfa1bfce3
Awaiting signature
Courtney Bell
Party ID: 5affc3a0-2a31-4397-af17-5492e1bc7b15
Awaiting signature
Chandra Brenoel
Party ID: 5ef189bc-2333-4db3-8144-aee7458e0f24
Awaiting signature
Chrissy Crutcher
Party ID: 0a14ce87-4bbb-4e34-b131-5d0620c78c59
Awaiting signature
Chad Perkins
Party ID: 6aa335c5-e722-40b0-a570-696d01f0e531
Awaiting signature
Luis Escobar
Party ID: 635e739d-8c7a-4179-b032-76b23dfd6f89
Awaiting signature
ENNU Patient Docs
Party ID: 99cf213d-eb99-4009-90a9-c0126770f20b
Awaiting signature
Shelby Carter
Party ID: 5e5b8280-57bf-4140-bbdf-fe02cbf83a4d
Awaiting signature
malloriemmayer@gmail.com
Party ID: eeef6fad-0946-4a0c-b63b-3d085ee650da
Awaiting signature
Karen Bridges
Party ID: 99a9f2b9-0d25-44ed-a957-67c5e0288e92
Awaiting signature
Lacreta Eskam
Party ID: 0aee29bb-78b0-45b8-acf7-7d6b4534b039
Awaiting signature
Cindy Clegg
Party ID: 4a97f8b0-c804-414a-a525-b535d3c491d9
Awaiting signature
Rowan Schaefer
Party ID: 3aff0ffe-f160-4729-89f5-fd8fcdb922a2
Awaiting signature
Lee Ann Hamblen
Party ID: 55d81271-5d5d-40ab-b104-c0791a7a5924
Awaiting signature
Laura Johnson
Party ID: cbf66350-d7d5-4b47-af8c-13bcf4744c33
Awaiting signature
Caitlin Protenic
Party ID: 08de481c-4b20-4f29-94e6-ea2ead053a49
Awaiting signature
Kathleen Talley
Party ID: 5a4454ee-e65c-46a4-93a6-fd9537e0e81f
Awaiting signature
Kristen Cook
Party ID: d9aa78cb-60f5-445c-9544-4933d88e9508
Awaiting signature
Gina Jacobs
Party ID: 16a32879-a6f8-4e9c-bf21-117608d8ad6d
Awaiting signature
Amy Whitby
Party ID: 2323d9e7-7a0b-43a4-a0a6-8f7075b45428
Awaiting signature
Emily Burton
Party ID: 52c663e0-3257-4f14-b155-f3bd2a769c11
Awaiting signature
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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