Sculptra PLLA Consultation/Consent Form | Aesthetics Forms Portal - Paperless Mission Control

Sculptra PLLA Consultation and Consent Form

Model Details

Full Name: *

Full Name: *

Contact Number: *

Date of Birth: *

Email: *

Medical History

Please list: *

Are you currently taking any medications (oral or topical)? *

Please list: *

Are you currently receiving any medical treatment? *

Do you have any allergies? *

Please list: *

Are you (or is there a possibility you may be) pregnant, or are you breastfeeding? *

Have you been unwell recently? *

Which of the following were you unwell with? *

Please provide more details: *

Do you have any surgery planned in the next 6 months? *

Please provide more details: *

Do you have any cutaneous (skin) infection or inflammatory problems (e.g. herpes/cold-sores, acne etc.)? *

Please provide more details: *

Are you taking any steroids, aspirin or anticoagulant (i.e. warfarin, apixaban etc.)? *

Please provide more details: *

Do you have any history of anaphylactic shock or severe allergic reactions? *

Please provide more details: *

Do you tend to develop hypertrophic scarring? *

Please provide more detail: *

Have you previously had any Sculptra PLLA? *

Which treatment did you receive, what areas were treated and when? *

Have you previously had any sensitivity to Poly-L-Lactic Acid Based Aesthetic Injectable Fillers? *

Please specify: *

Are you undergoing any dental work or have any dental work/hygienist planned? *

Please specify: *

Do you have any metal plates in your face? *

Please provide more detail: *

Have you taken any Aspirin, Ibuprofen, Fish Oil, Vitamin E in the last five days? *

Please specify: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Poly-L-Lactic Acid Based Aesthetic Injectable Fillers: Sculptra® Treatment

What Is Sculptra® Aesthetic Injection: Sculptra® or poly-L-lactic Acid is a bio-stimulator injectable that helps encourage the body to produce collagen in the areas it is injected. It is typically used in areas not treated with standard volumetric fillers. Sculptra® is not a volumetric filler but does help to gradually smooth lines, naturally volumizing and rejuvenating the face. Your treatment provider will begin by cleansing treatment area and applying or injecting a topical or local anesthetic to reduce discomfort. Once you have been sufficiently numbed, Sculptra® is injected into the dermal layer of the skin; your provider will use a cotton swab to massage the treatment area to help spread the filler. You can expect minor discomfort during the treatment related to the injections. Results cannot be seen immediately and are typically seen within 4-6 weeks with results lasting up to two years. Multiple Treatments (3-6 sessions) are typically required to achieve desired results. Duration of treatment is dependent upon treatment location(s) but the average treatment is around 15-30 minutes. Minor redness, pin-point bleeding, itching, discomfort or tenderness, and bruising are common side effects after treatment. There is no expected downtime with Sculptra® and most clients are able to resume normal activities the day after treatment.

I understand the treatment goal is to increase collagen production and improve skin firmness, skin appearance, and/or facial volume; multiple treatments may be necessary in order to achieve desired results; results are temporary and maintenance treatments may be required to maintain desired results.

What would you like the treatment to improve or change about your appearance? *

I understand the treatment goal is to increase collagen production and improve skin firmness, skin appearance, and/or facial volume; multiple treatments may be necessary in order to achieve desired results; results are temporary and maintenance treatments may be required to maintain desired results. *

YES

Possible Risks and Complications

Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free.

The possible risks of Sculptra PLLA include, but are not limited to:

General Side Effects: I understand there is a risk of swelling, discomfort, pinpoint bleeding, local numbness, pain at the treatment site, bruising, allergic reaction, damage to deeper structures, or irritation of the skin that may occur.
Infection: Although rare, if an infection occurs as a result of treatment, additional treatment including antibiotics or an additional procedure may be necessary.
Bleeding/Bruising: It is possible, though unusual, to have minor pinpoint bleeding during treatment. Bruising in soft tissues may occur. Should you develop post-treatment blood clot or bleeding, you may require emergency treatment or surgery. Aspirin, anti-inflammatory medications, platelet inhibitors, anticoagulants, Vitamin E, ginkgo biloba, and other “herbs / homeopathic remedies” may contribute to a greater risk of a bleeding problem. Do not take these for ten days before or after your Sculptra® treatment.
Skin Redness, Swelling, and Discoloration: It is common to have temporary redness and swelling following treatment. This will usually subside in the first few hours after a session, but may last for several days to a week. Minimizing exposure to excessive sunlight, UV lamps, and extreme cold weather until all swelling and redness subsides is recommended. Avoiding use of alcohol for the first 24 hours is recommended. Discoloration may occur at treatment site, which is typically temporary and self-resolving, but may also become permanent.
Damage to Deeper Structures: Deeper body structures such as nerves, blood vessels, glands, and muscles may be inadvertenly damaged during aesthetic treatments. The potential for this to occur varies according to where the treatment is being performed and the treatment type. Injury to deeper structures may be temporary or permanent.
Scarring: Scarring is a rare occurrence, but is a possibility when the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff
Nodules, Bumps, and Granulomas: In a small percentage of Sculptra® patients, small lumps can appear underneath the skin due to clumping of Sculptra® particles. These lumps are often not large enough to be visible and can only be noticed by touching the skin. Sometimes they are accompanied with bruising or discoloration of the skin and may not appear until 6-12 months post-treatment. In rare cases, larger, disfiguring lumps may appear at the treatment site and may require additional treatment.
Induration at Treatment Site: a feeling of fullness or thickness (known as induration), may be felt at injection site. Should this occur, your provider may discuss massage or other forms of treatment to alleviate this feeling.
Discomfort: You may experience some discomfort during and after your treatment.
Allergic Reactions and/or Contact Dermatitis: Allergies to topical local anesthetic preparations and/or sensitivities to metals used in the injection needle may occur. If you experience an allergic reaction, you may require additional treatment. Potential increased sensitivity, irritation/itching, or allergic reaction due to skin surface disruption.

Post Treatment & Results

Results: Immediate results will not be seen after each treatment. Collagen building takes place over 4-6 weeks after treatment, with maximum results seen at 6 months after last treatment.
Multiple Treatments: it is recommended to have a minimum of 3-6 treatments to achieve desired results. Each treatment should be 4-6 weeks apart for maximum benefit.
Once desired results are achieved, maintenance treatments may be scheduled annually to maintain results.
Please do not plan to attend any important events 2 weeks post-treatment to allow for any bruising, swelling, or redness to subside.
It is normal to feel bumps or nodules under the skin when pressing on the treated area. If these nodules become painful or do not resolve within a few months, please call treatment provider.
The microparticles of Sculptra may be radiopaque and visible on CT scans, MRI, ultrasound or X-Rays for 90+ days. Please inform your doctor that you've had Sculptra® if having these tests.

Aftercare Advice

The goal of aftercare is to encourage optimal treatment results. It can also minimize the risk of bruising and spreading to other areas. Follow the aftercare advice provided for optimal results.

PLEASE DO NOT:

1. Do NOT expose treatment area to excess heat and sunlight for 2 weeks post-treatment, which may increase swelling and bruising at the treatment site.

2. Do NOT have chemical peels, laser skin resurfacing, laser skin tightening, and other laser enhancements for 2 weeks post-injection as these treatments may cause excess inflammation.

3. Do NOT engage in strenuous exercise that can cause sweating, jacuzzi, sauna or steam baths for 24 hours due to open pores, or up to 48 hours if inflammation/swelling is present. You can return to work 1 day after treatment.

4. Do NOT apply makeup, lotions, or topical products for at least the first 24 hours after treatment.

PLEASE DO:

1. Sleep on your back with your head elevated at least 30º for the first 3 nights to minimize swelling.

2. If desired, use Arnica cream or capsules a few days before and a few days after treatment to help reduce bruising. Use as directed on the container.

3. Massage treatment area with clean hands in a circular fashion for 5 minutes up to 5 times per day for the first 5 days.

4. Gently wash treated area daily with cool water and gentle cleanser and pat to dry for 5-7 days.

5. Cold compresses may be used 20 minutes on 20 minutes off to reduce swelling 2-3x per day during the 1st 1-2 days if needed.

6. Understand it is not uncommon to experience the following for the next 1-5 days: redness, pinpoint bruising, mild inflammation, soreness, and mild swelling. If you experience an increase in these symptoms after the first 72 hours, please call the office for a follow-up. You may apply cold compresses, take acetaminophen (Tylenol), and sleep elevated to help reduce discomfort

7. Avoid prolonged exposure to sunlight/heat/UV for the first 2 weeks; use sunscreen daily on face as soon as inflammation has subsided.

8. Please call if you experience any of the following in treatment area: increasing pain, increased swelling or warmth, skin blanching (white or pale appearance), and red/inflamed nodules.

Please click the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the academy immediately.

I fully understand the above and consent to receive Sculptra PLLA.

Signature: *

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