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Download sculptra consent - Facial Techniques
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SCULPTRA CONSENT Patient Name _____________________________________________________ DOB ___________________ A natural, youthful face is full and not tight. Age related changes of the lips and mouth include atrophy of the lips and atrophy of the corners of the mouth, resulting in downturn. Another early sign of aging is the development of nasolabial lines. Sculptra is a safe, synthetic, and biocompatible material that is injected below the surface of the skin. It’s made up of microspheres (a spherical shell that is usually made of biodegradeable or reabsorbable plastic polymer, that has a very small diameter usually in the micrometer or nanometer range, and that is often filled with a substance, as a drug or antibody, for release as the shell is degraded) of poly-L-lactic acid forty to sixty microns in size. Because poly-L-lactic acid is the main ingredient in Sculptra, patients don’t require a test for allergic reactions. Sculptra is approved to treat lipoatrophy, the progressive facial decomposing seen on most HIV patients, but it is used “off-label” for cosmetic purposes. Regardless of the type of filler used, I understand that the actual degree of improvement cannot be predicted or guaranteed. Not all wrinkles will respond to Sculptra. Furthermore, I understand that the effect will gradually wear off and additional treatments may be necessary to maintain the desired effect. Side Effects and Complications - Include but are not limited to: • Delayed appearance of small bumps under the skin in the treated area • Bleeding • Tenderness or discomfort • Redness, bruising or swelling at site of injection Precautions and Contraindications • You should not have a history of a bleeding disorder, abnormal scarring or an autoimmune disease. • The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as aspirin and non-steroidal anti-inflammatory drugs (e.g. Ibuprofen, Aleve, Motrin, Celebrex), high doses of Vitamin E, and certain herbs (Ginkgo Biloba, St. John's Wart). • The safety of Sculptra in pregnant or breast-feeding women has not been established, and is therefore not recommended for these women. • You should notify the office if you have a history of herpes simplex (cold sores). I have requested that Facial Techniques technician attempt to improve my nasolabial folds with SCULPTRA. I understand that there are NO GUARANTEES as results vary from person to person. I consent to be photographed before, during and after treatment. These photographs shall be the property of Facial Techniques. These photographs may be shown for scientific reasons, and/or used in patient education (both in and out of the office). I understand that I release Facial Techniques, the Medical Supervisor, the technician performing services and any Facial Techniques employee involved in my treatment from any liability associated with complications from the Sculptra procedure. I CONSENT TO THE TREATMENT OR PROCEDURE OF SCULPTRA. SIGNATURE __________________________________________________________ DATE ____________________ WITNESS _____________________________________________________________ DATE ____________________ FACIAL TECHNIQUES. 8140 WALNUT HILL LN. STE 601. DALLAS TX 75231. 214-346-5438
