Sculptra Consent Form

Sculptra Consent Form
Please read the following information carefully and provide your consent for the Sculptra treatment.
Patient Information
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Please indicate if you have any of the following conditions:
Do you have any allergies?
If yes, please list:
Are you currently taking any medications?
If yes, please list:
Have you had any previous cosmetic procedures?
If yes, please specify:
Treatment Information
I understand that Sculptra is an injectable treatment used for facial volume restoration. I acknowledge that I have been informed about the treatment, its benefits, and potential risks, including but not limited to: swelling, bruising, redness, and allergic reactions.
I have had the opportunity to ask questions regarding the treatment and have received satisfactory answers. I understand that individual results may vary.
By signing below, I consent to the Sculptra treatment and confirm that I have provided accurate information to the best of my knowledge. I understand that I may withdraw my consent at any time prior to the procedure.
Consent and Signature
Signature
Clear
Date of Consent
MonthDayYear
Date
Should be Empty:

Patient Information