Loading...

Sculptra® Informed Consent 

  • Sculptra therapy is the injection into the skin and underlying tissues of poly-L-lactic acid. Sculptra therapy is designed to help correct skin depressions, such as creases, wrinkles, folds, scars, hollow eye rings, degenerative skin aging, and facial lipoatrophy (loss of fat)
  • After each injection session, tissue volume in the treated area will gradually build up over the following weeks and months, as your body produces new collagen (neocollagenesis). At the time of your return visit for your next session of Sculptra therapy, your response to the previous treatment will be assessed and additional treatments can be performed if needed and agreed upon to optimize your correction. Sculptra therapy does not treat or cure the underlying cause or disease of tissue or fat loss; rather it is designed to improve the appearance of the affected area(s). I have been educated on some of the features, benefits, and possible risks involved with using Sculptra and have had my questions answered to my satisfaction. Some of these possible risks include: • After the injection(s) some common injection-related reactions probably will occur, these may include swelling, redness, pain, itching, discoloration and tenderness at the injection site. These typically resolve spontaneously, usually within 1 to 15 days after injection. • Because Sculptra therapy injections are administered in a solution containing water, there will be an initial swelling (edema) that will be noticeable for at least several hours and perhaps as long as several days. This effect is temporary, and does not affect the long-term tissue response. • Small bumps under the skin, termed micro-nodules, which may be non-visible or visible, may be felt in the areas of treatment. Usually, these bumps may only be felt when pressing on the skin. Micro-nodules typically last from 6 to 12 months, and may spontaneously disappear. They usually do not require treatment, and usually do not have any symptoms. • Induration, or a feeling of fullness or thickness, can be felt in the injection area. This is a normal response of the treated tissue to the process of inflammation and neocollagenisis. Simply massaging the treated areas gently 3 to 5 times per day for 3 to 5 minutes, for 3 to 5 days after the injection can help minimize induration. • Visible bumps may occur in rare instances, and they may be associated with redness, tenderness, skin discoloration or textural alteration. These bumps, which may be termed granulomas, may or may not require treatment, including but not limited to, injections, freezing, or excision. • Other rarely reported adverse events include: injection site abscess, allergic reaction, skin hypertrophy and/or atrophy, malaise, fatigue, and edema. • Sculptra therapy is contraindicated (not allowed) in pregnancy or during breast feeding. If you believe you may be pregnant or are breastfeeding, please inform the provider prior to injection. • Sculptra therapy has been approved by the United States Food and Drug Administration (FDA), for the restoration and/or correction of facial fat loss (lipoatrophy) in people with HIV and for aesthetic (cosmetic) use. Sculptra therapy (New-Fill) has been performed since 1999 in more than 150,000 patients in more than 30 countries, principally for cosmetic use.  

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR SCULPTRA®, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM. 

Date: February 22, 2026

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information

I acknowledge the following points have been discussed with me:

First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I acknowledge the following points have been discussed with me:

Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information

I acknowledge the following points have been discussed with me:

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!