|
Sculptra Contraindications
|
|
|
Pregnant or Breastfeeding
|
|
|
Lidocaine Allergy
|
|
|
Hx Keloid or Hypertrophic Scarring
|
|
|
Hx Severe Allergies or Multiple Allergies
|
|
|
Autoimmune Hx with current flare up?
|
|
|
Hx Bellafill injections?
|
|
|
Hx Migraines / Jaw Clenching
|
|
|
Risks/Benefits Reviewed and questions answered
|
|
|
Sculptra Treatment
|
|
|
Areas Treated
• • •
|
|
|
Total Number of Vials
|
|
|
Temple Volume
|
Zygomatic Volume
|
|
Submalar Volume
|
Pre-Auricular Volume
|
|
Jawline Volume
|
Chin / Labiomental Volume
|
|
Nasolabial Volume
|
Pyriform Fossa Volume
|
|
Neck Volume
|
Decolletage Volume
|
|
Hip Volume
|
Buttock Volume
|
|
Needle / Cannula
• • •
|
|
|
Lot / Expiration Date
|
Lot / Expiration Date
|
|
Lot / Expiration Date
|
Lot / Expiration Date
|
|
Lot / Expiration Date
|
Lot / Expiration Date
|
|
Bruising Present post injection?
|
Massage of areas treated?
|
|
Arnica Applied & Provided to Patient?
|
|
|
Before Photo
|
Before Photo
|
|
Before Photo
|
Before Photo
|
|
Before Photo
|
Before Photo
|
