I hereby give consent and request Dr. Patrick Yam, PRP Skincare & Laser Ltd, and appropriate designated technical assisstants to perform the process of a PRP injection treatment with or without ACell MatriStem® acellular matrix ("ACell") for the purpose of promoting hair growth. I also consent to other medical services during the procedure that may become medically reasonable and necessary. This includes, but is not limited to, venipuncture for the purpose of obtaining a blood sample to prepare the PRP and the administration of anaesthetic (e.g. injection, inhaled, topical), to perform the procedure with improved comfort.

I understand and accept the following risks of this procedure:

Experimental and off-label: I understand that although platelet-rich plasma (PRP) and ACell are approved by Health Canada as medical therapies, their use as a treatment for alopecia is still considered investigational and off-label. As such, studies are ongoing to help determine their effectiveness. Established therapies for alopecia include topical minoxidil solution and oral DHT blockers such as finasteride.
Trauma: Caused by needles passing through tissue, including bleeding, bruising, hematoma (a larger collection of blood in the tissue, outside of the blood vessels), damage to underlying structures including veins, arteries, nerves, salivary glands, lymph nodes, bone, muscle, and other soft tissue structures. In rare cases this could cause ongoing problems with appearance, sensation or function and may require medical intervention to treat or may be permanent. Most traumatic injuries heal completely on their own.
Reactions:  The risk of allergic reaction during this procedure is considered very low from PRP as it is obtained from a sample of your own blood. However, anesthetic medication is also used, such as lidocaine, xylocaine, tetracaine. In addition, calcium chloride solution 10% may be used to activate the PRP. Acell is made from porcine (pig) bladder cell culture (but the cells are removed). By agreeing to this procedure you certify that you are not aware of any known allergy or sensitivity to any of the above components. Anaphylactic shock has a mortality rate 0.3 to 5% depending on the study. An allergy test can often identify this risk prior to full exposure.    
Side Effects: Local reactions include edema, erythema, pain and itching, urticaria and angioedema. Nerve injury including altered sensitivity and/or pain, lasting up to a few days but possibly longer may occur from the injections.    
Treatment failure:  It is possible that this procedure will not slow down or reverse hair loss. It is also possible that hair loss may be increased due to the procedure. Sometimes this loss is experienced as increased shedding, which may or may not be temporary. It is often difficult or impossible to know for certain what is causing increased hair growth or loss due to multiple factors involved in hair growth and loss.      
Complications from infection:  With this procedure, there is a small risk of introducing an infection, or worsen pre-existing infection due to injection into the area, risking septicemia though there are no recorded cases.      
Delayed results: I understand that results are not immediate. It can take up to 3-4 months for results to start to become noticeable and often full results are not noticeable for up to a year.         
Dissatisfaction: I understand and accept that results cannot be guaranteed and may never be as good as I would like them to be.

Recommended Treatment Protocol
The current recommended treatment protocol is as follows:
For PRP alone: 3-4 treatments, at one month intervals, followed by a maintenance treatment every 6-12 months.
For PRP with Acell: 1-3 treatments, given at 3 month intervals, followed by maintenance treatment every 6-12 months.