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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:

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

Farida Shadman

farida.shadman@uoflhealth.org

Emily Burton

e.burton15@hotmail.com

Farida Shadman

farida.shadman@uoflhealth.org

Emily Burton

e.burton15@hotmail.com

Farida Shadman

farida.shadman@uoflhealth.org

Emily Burton

e.burton15@hotmail.com

Farida Shadman

farida.shadman@uoflhealth.org

Emily Burton

e.burton15@hotmail.com

Amy Whitby

amylee2282@yahoo.com

Amy Whitby

amylee2282@yahoo.com

Gina Jacobs

gmjacobs125@gmail.com

Kristen Cook

kristen.leigh25@icloud.com

Kristen Cook

kristen.leigh25@icloud.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Kathleen Talley

kschroeder49@yahoo.com

Caitlin Protenic

catieyatie@gmail.com

Laura Johnson

beaweinspiring@gmail.com

Lee Ann Hamblen

hamblen875@gmail.com

Rowan Schaefer

rgscha02@gmail.com

Cindy Clegg

clc41968@gmail.com

Lacreta Eskam

eskam1@att.net

malloriemmayer@gmail.com

Karen Bridges

msmbridges23@icloud.com

malloriemmayer@gmail.com

Shelby Carter

Shelbyncarter91@gmail.com

ENNU Patient Docs

admins-ennu@ennu.co

Luis Escobar

l_esco@me.com

Chad Perkins

Chadaperkins52@yahoo.com

Chrissy Crutcher

chrissycrutcher@yahoo.com

Chandra Brenoel

chandrab.hct@gmail.com

Courtney Bell

courtneybell@ymail.com

Makenzie Barnes

makenzie.barnes2@gmail.com

NEXT

Sculptra Treatment Consent

Sculptra Treatment Consent

(Aesthetics)

Patient Information

Treatment Information

Consent Statements

Please Review & Sign This Document

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