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from experienced professionals
“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

SCULPTRA® is an injectable implant that contains micro particles of L-Poly- Lactic Acid, a biocompatible, biodegradable synthetic polymer from the alphahydroxy-acid family.

Signing this consent will stipulate that you understand and agree to the following:

  1. I understand that I should not use this product if I am allergic to subcutaneous, absorbable suture material. I have shared with the doctor my complete medication list and medical history; particularly bleeding disorders, previous cosmetic surgical procedures, keloid scar history, and history of facial herpes.
  2. I understand that this product needs to be reconstituted at least 2 hours before use, therefore I agree to put a deposit down before my appointment in case I have to cancel and the product is wasted.
  3. I understand that this product is FDA approved in the United States for the treatment of facial lipodystrophy in HIV+ patients who are taking anti-retroviral medications. I understand that this product has been used in Europe and South America for years for soft tissue augmentation / volume repletion. I understand that the use of this product for soft tissue augmentation / volume repletion in the United States is considered an “off-label” use of this product.
  4. I understand that the injection procedure reactions are: Temporary numbness and tingling from local anesthetic, bruising, hematoma formation, discomfort and erythema.
  5. I understand that the risks of these injection procedure reactions are greater if I have been drinking any alcohol, taking any aspirin or NSAIDS (such as Advil, Motrin, Ibuprofen, Naproxen, Aleve, etc.), or taking large doses of Gingko Biloba or more than 400 IU of Vitamin E per day.
  6. I understand that the most common device related adverse effect is the delayed occurrence of subcutaneous papules, which were confined to the injection site and were typically palpable (could be felt), asymptomatic and non-visible. I understand that there is a chance of infection at injection sites, which is rare and treatable with routine antibiotics.
  7. I understand that I need to apply ice to the areas which are treated for 10-15 minutes each hour for the first 6-8 hours to minimize bruising. I understand that I need to massage the treated areas each night for 5-7 days.
  8. I understand that it takes several weeks to see the effects of this treatment, and the appropriate way to do this is to “treat, wait and reassess” in 4-6 weeks. I understand that several vials of Sculptra®, and/or several treatment sessions may be necessary to achieve the results I desire.

Please download this PDF form to sign.





Petaluma Office
165 Lynch Creek Way
Petaluma, CA 94954
 M-F, 8:00am-5:00pm
(707) 762-5531
Fax: (707) 762-5976



Hercules Office
500 Alfred Nobel Dr., Ste. 245
Hercules, CA 94547
M-F, 8:00am-5:00pm
Open Saturday for aesthetic services
 (510) 741-7418
Fax: (510) 741-7456


Billing office
Fax: 510- 741-7493

At Dermatology Associates of the Bay Area, our board-certified dermatologists serve patients at our Petaluma and Hercules offices. We are committed to the highest standards, and we offer a full range of cosmetic, medical, and surgical dermatology procedures, as well as quality skin care products.

Dermatology Associates of the Bay Area
165 Lynch Creek Way | Petaluma, California 94954 | Phone: (707) 762-5531 | Fax: (707) 762-5976
500 Alfred Nobel Drive, Suite 245 | Hercules, California 94547 | Phone: (510) 741-7418 | Fax: (510) 741-7456