INTRODUCTION
Sculptra Dermal Filler consists of micro particles of a substance called PLLA, Poly-L-Lactic-Acid. A kind of lactic acid, in other words. When the micro particles are injected into the skin, they gradually stimulate the skin’s natural production of collagen, thereby renewing its natural firmness.
PLLA is biodegradable so with time, the particles will dissolve and disappear, but the new collagen will remain. This means that the resulting firmer skin will be due to natural collagen formation. Sculptra Dermal Filler provides a gradual improvement, and the skin continues to improve for a long time. People who’ve had a Sculptra treatment have continued to show improvement up to 25 months after treatment.
INSTRUCTIONS
This is an informed consent document to help you understand Sculptra Dermal Filler risks, likely effects and alternative treatments. You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.
ALTERNATIVE TREATMENTS
Other “filler” materials exist that have similar effects such as collagen, fat grafts, Sculptra and Radiesse. Also, laser resurfacing and chemical peels can improve certain wrinkles. Certain deeper wrinkles may require surgical treatments, such as brow or face lifts.
POSSIBLE SIDE EFFECTS
Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo this procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following, you should discuss each of them with your physician to make sure you understand the risks, potential complications, limitations, and consequences of injections.
- Allergic reaction or infection. Bleeding, tenderness or pain, redness, bruising or swelling at injection site, which can last from 3-17 days. Delayed side effects can include small bumps under the skin in the treated area. These bumps may not be visible and may only be noticed when you press on the treated skin. Bumps tend to occur within the first 6-12 months after the first treatment and may go away on their own.
- Sculptra should improve the appearance of facial fat loss by increasing skin thickness in the treated area but will not correct the underlying cause.
- I understand that there have been no long term studies carried out on the effects of the use of Sculptra.
- I understand the Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications as listed above.
- I understand that I will be injected with Sculptra Dermal Filler.
- I understand that multiple treatments are necessary to achieve desired results. Treatments tend to last up to 2 years. Touch up treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.
- I have provided Beauty Marx with a complete medical history and I do not suffer from any autoimmune diseses such as lupus, rheumatoid arthritis etc.
I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
I release Beauty Marx, entire staff and providers from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
Note: All prices are subject to change without prior notice
1. I HEREBY AUTHORIZE Beauty Marx Aesthetics to perform the following procedure or treatment: Sculptra
2. I release all medical staff and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
3. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.
4. I consent to the photographing of procedure(s) to be performed, including appropriate portions of my body, for medical, social media, or educational purposes, provided my identity is not revealed by the pictures.
5. It has been explained to me in a way that I understand:
a.The above treatment or procedure to be undertaken.
b.There may be alternative procedures or methods of treatment.
c.There are risks to the procedure or treatment proposed.
*All prices are subject to change without prior notice*
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS. I AM SATISFIED WITH THE EXPLANATION.