PS Worldwide Ltd T/A Professor Laurence Kirwan
56 Harley Street, London, W1G 9QA Tel: 0207 637 4455
Nominated Individual: Laurence Kirwan / VERSION 1.0
Patient Name: First: ___________________ Last:_______________________
Date of Birth:
/
/
Address: ______________________________________
INFORMED-CONSENTSCULPTRA
What is SCULPTRA® and how does it work?
It is based on polyl-L-lactic acid, which has been used in medicine and surgery for over 20 years. Initially the
line or wrinkle is filled by the gel consistency of the substance but following this: the poly-L-lactic acid induces
the stimulation of the body's own collagen.
Has it been adequately tested? It has a CE mark for use in this country which means it has been through the
necessary clinical trials for safety and efficacy.
How long will it last? Products last a different length of time according to many different factors such as the
structure of the skin, lifestyle and age. However, clinical trials show evidence of the improvements remaining
at least 12 months. A complete treatment is at least 2 sessions spaced approximately 2 weeks apart.
Will it hurt? Many customers feel quite comfortable during treatment but as with all injectable products the
penetration of the needle may be momentarily painful at the point of injection. The doctor may use a local
anesthetic or a dental anesthetic.
Are there any side effects? The product is based on lactic acid which occurs naturally in the body and it
contains no animal proteins whatsoever. Hence there is no need for a skin test. You should not, however,
have taken any aspirin related product up to 48 hours to treatment as this may cause excessive bleeding or
used Retinol A on your skin recently.
How long will it take? The treatment takes about 30 minutes, so it need not impact too
greatly on your daily schedule.
Can I wear make up afterwards? If possible, leave make up off for 12 hours.
What areas can be treated with SCULPTRA®? Deep facial depressions and furrows. Also, to put volume
into cheek depressions, lips, facial outline, chin. Scars can also be treated. Soft tissue augmentation.
When will I see the results of the treatment? Immediately after the injection of the line or wrinkle will be
corrected, however, this is followed by a period of about a fortnight during which time the result may appear
to regress. This is normal as it is followed by the commencement of new collagen production. The final result
should be visible approximately 2 weeks after the second session.
SIDE EFFECTS AND ADVERSE REACTIONS: SCULPTRA®, like any medication, may have possible side
effects. These include bruising at the injection site; pain during injecting; slight swelling and/or redness; or
headache. If inadvertently injected into a blood vessel, it could lead to superficial necrosis (darkening and
scabbing) at the injection site and, in rare cases, possibly amaurosis (blindness). Hypersensitivity (swelling,
indurations, erythema, tenderness and acneform) may occur in about one in 2000 patients receiving these
products. This is treatable and transient. Please notify the office if any of these effects occur.
Page 1 of 3 Patient Initials ______
Revised 9 May 2014 / Review 8 May 2015
PS Worldwide Ltd T/A Professor Laurence Kirwan
56 Harley Street, London, W1G 9QA Tel: 0207 637 4455
Nominated Individual: Laurence Kirwan / VERSION 1.0
Patient Name: First: ___________________ Last:_______________________
Date of Birth:
/
/
Address: ______________________________________
INFORMED-CONSENTSCULPTRA
CONTRAINDICATIONS: Discuss with your physician the suitability of using SCULPTRA® at a site that was
previously injected with another filling material. CONSENT: I have informed my practitioner of all, any and all
other filling agents that have been used on my skin the past. I have informed by practitioner of all the
medications I am currently taking. I hereby request, authorize and give my consent to Dermis, P .C. to
perform the treatment described above. My signature indicates that I have read and understand all the
information presented to me, and have had any questions answered.
Patient's Signature: __________________ Date: _______________________ Witness' Signature:
I have fully explained to this patient the nature and purpose of the treatment. I have asked the patient if he or
she has any questions regarding this treatment and have answered those questions to the best of my ability.
Practitioner's Signature: ___________ Date:
Page 2 of 3 Patient Initials ______
Revised 9 May 2014 / Review 8 May 2015
PS Worldwide Ltd T/A Professor Laurence Kirwan
56 Harley Street, London, W1G 9QA Tel: 0207 637 4455
Nominated Individual: Laurence Kirwan / VERSION 1.0
Patient Name: First: ___________________ Last:_______________________
Date of Birth:
/
/
Address: ______________________________________
INFORMED-CONSENTSCULPTRA
SCULPTRA®
After Care Information
•
Keep treated area clean and dry
•
Massage the treated area thoroughly as instructed by you practitioner
•
Do not apply any creams other than those specified by your practitioner
•
If possible leave make-up off for 12 hours
•
Swelling may occur but will disappear
•
Bruising may occur but will disappear
•
If you have suffered from cold sores then any lip treatment may cause a recurrence.
•
If you take aspirin bruising and bleeding may be increased
•
Ensure repeat treatment appointment is made
•
If any concerns, please call your practitioner
Page 3 of 3 Patient Initials ______
Revised 9 May 2014 / Review 8 May 2015