PLATELET RICH PLASMA (PRP) INJECTION CONSENT FORM

Name*

First NameLast Name

Date of Birth*

Date

Please indicate the areas where you are requesting PRP injection

Face including PRP MicroneedlingUnder eye PRP (dark circles, volume loss)Other skin (e.g. scars) on the body or faceMSK - muskuloskeletal - e.g. joints, muscles, tendons, arthritisPRP Hair restorationWomen: genitourinary area (O-Shot for urinary incontinence or sexual function)Men - Penis for Priapus® shotOther

What benefits are you hoping to acheive?

REASONING:

I have been advised that PRP is used to stimulate the body to repair and regenerate weak and damaged connective tissue which are believed to cause pain and instability. It is also used to decrease pain and improved function in some forms of arthritis. The procedure requires the injection of PRP derived from a small sample of my own blood, according to standard preparation techniques. The injection is localized to the area of concern.

I have been informed that the procedure has been used on many patients and has been proven safe. The procedure may initially increase my painful area or reproduce my symptoms for one to three days (and occasionally as long as ten days) and then may decrease my pain complaints, but may not completely eradicate them. I understand that although the use of PRP is supported by known scientific principles and understanding of platelet physiology, PRP treatments are still considered to be experimental due to the lack of large research studies in the scientific literature.

ALTERNATIVE TREATMENTS:

Alternative treatments have been reviewed with me including: doing nothing, other injections such as steroids or local anesthetics, physical therapy, energy devices including ultrasound and shockwave, acupuncture, and surgical intervention.

BENEFITS:

I understand the potential benefits of the procedure are improved or resolved pain and improved function. I understand and acknowledge that results cannot be guaranteed, individual response varies, and multiple treatments may be recommended for best results.

RISKS AND COMPLICATIONS OF PRP INJECTIONS:

Overall, PRP is considered very safe and the risk of allergic reaction is very low, as PRP is derived from a sample of the patient’s own blood. However all procedures carry risk. The risks of this procedure have been explained to me, including bleeding, bruising, infection, and damage to nearby tissues, vessels, nerves. Other risks for this procedure may include: headache, no decrease in pain, or an increase in pain.

OTHER POSSIBLE RISKS OF PRP INJECTIONS AND/OR MICRONEEDLING:

Bleeding, infections, no effect at all, allergic reactions, alteration of facial features, hematoma or bruising, hyperpigmentation, hypopigmentation, need for subsequent surgery, scar formation, local tissue infarction and necrosis, erosions, fatigue, damage to eyes, ears, nose, mouth, procedural pain, post-operative pain, prolonged pain, intractable pain, failed procedure, varied results, psychological alterations, relationship problems, possible hospitalization for treatment of complications, lidocaine toxicity, anesthesia reaction, embolism, depression, reactions to medications including anaphylaxis, nerve damage, permanent numbness, slow healing, swelling, allergy, nodule formation.

CONTRAINDICATIONS:

Absolute contraindications include: Critical thrombocytopenia; Hemodynamic instability or septicemia; active or chronic infection for example: cellulitis, or adjacent osteomyelitis; chronic liver disease; platelet abnormalities; platelet dysfunction syndrome

Relative contraindications include the following: Regular nonsteroidal anti-inflammatory drug (NSAID) use within 48 hours of the procedure; corticosteroid injections within 1 month or systemic corticosteroid use within 2 weeks; recent fever or illness; cancer, particularly of bone or blood; anemia, with a hemoglobin level lower than 10 g/dL; Thrombocytopenia, with a platelet count lower than 105/μL

Please indicate if you have ever any of the following conditions*

	Yes	No	Unsure
Thrombocytopenia (low platelet count)
Anemia (low hemoglobin)
Liver disease
Cancer
Bleeding or clotting disorder
Fainting during blood test
Hepatitis C, HIV, or other infectious disease

If "yes" or "unsure" to any of the above, please provide details here:

I understand photographs and/or video or electronic recordings may occur during my procedure and may be used for internal performance improvement or educational purposes.

I understand that this treatment is voluntary and I agree to pay all costs associated with the procedure myself. I understand that results are not guaranteed and no refunds will be given.

I CONSENT TO RECEIVING PRP INJECTIONS AS DETAILED ABOVE:

Signature

Print Name