CONSENT FOR PRP HAIR RESTORATION INJECTION PROCEDURE

Date*

Date

I First Name* Last Name* , hereby give consent to New Skin and Body Aesthetics Inc. to perform a PRP injection procedure. I also consent to any other medical services during the procedure that may become medically reasonable and necessary. This includes, but is not limited to, the administration of topical or injectable anesthetics necessary to perform PRP injections

2. I have declared that I have allergies to*

N/A if blank

3. I have declared that I take the follow medications*

put N/A if no allergies

4. I understand that PRP can be used to treat hair loss. I fully understand the results that I may reasonably expect. I understand that not all patients get improvement. Initial*

Initial

5. I declare I do not have any of the following conditions which might otherwise not make me a candidate:

Current Infections*

YES or NO

Skin diseases such as lupus or porphyria*

YES or NO

Current cancer*

YES or NO

Current chemotherapy treatments*

YES or NO

Severe metabolic or systemic disorders*

YES or NO

Liver disease *

YES or NO

Abnormal platelet function (blood disorder)*

YES or NO

Anticoagulation therapy*

YES or NO

Current use of corticosteroids (Steroid injections) in my scalp in the last month*

YES or NO

HIV*

YES or NO

6. An explanation of the procedure has been given to me. I understand that blood will be drawn from a vein in my arm. That blood will then be placed in a centrifuge to be spun down in order to concentrate the platelets and then injected back into my scalp. I understand that local freezing medications will be given to reduce discomfort of the PRP injections. I understand I may have some post procedure discomfort and even swelling*

Initial

7. I am aware of the pros, cons and alternatives to PRP injections. I have the option of doing nothing, wearing a wig or hairpiece, using prescription medicines or possibly having a hair transplant surgery. A combination of the above is also possible. I understand that the PRP injection procedure is an "elective" procedure. If I do not have PRP injections, I will not experience harm or negative consequences for my body other than potentially losing more hair.*

Initial

8. I agree that the procedure recommended by New Skin And Body Aesthetics Inc. are the best recommendations at the time of consultation, consistent with my current level of hair loss.I agree these recommendations may later need to be modified depending on future developments in my hair loss, changes in my own goals or technology.*

Initial

9. I understand that hair loss is sometimes continuous throughout life for some people. I understand that additional PRP injection procedures may be needed and that some individuals would expect 1-3 sessions per year.*

Initial

1. Minor discomfort (pin prick sensation) from blood draw

2. Dizziness and feeling faint (rare)

3. A temporary headache

4. Redness in the scalp for 2-4 days

5. Swelling in the forehead and around the eyes. There although rarely maybe swelling discoloration and bruising associated with the procedure. 6. Reaction to local anesthetic medications

7.Hair loss (temporary) in the existing hair. This is often termed 'shock loss.

8. Infection (very rare)

9. Itching at the injection sites

10. Minor bleeding and bruising at the sites of injections

11. Injury to nerve during blood draw (very rare)

12. Numbness in the scalp that lasts more than 1 day (rare)

I have read and understand all of the possible side effects and complications listed above. I accept the risks of these possible complications and consequences associated with this procedure.

Last Name*

Email*

example@example.com

Patient Signature*

Date*

Date

Select your Provider*

Provider Signature*

Date*

Date

10. I consent to and authorize the performance of PRP Injections by New Skin And Body Aesthetics Inc. I understand that in some cases, we have other professionals observe and assist with this procedure. I authorize these individuals to be present and assist during my procedure and I have the right to state if I do not want such assistants present. Initial*

Initial

11. I consent to having my photos taken. These include pre-procedural (‘before’) photos, photos during the procedure (‘during’) and post-procedure (‘after’) photos. I understand these photos will not reveal my identity. I give consent to New Skin And Body Aesthetics Inc. to use these photos in teaching and research, including teaching of doctors, students, trainees and the general public. I consent to having photos used for advertising purposes, which may include brochures, websites and use during pre-procedural consultations. I understand that I may withdraw consent by stating ‘no consent for sharing photos’ on line 20 below. However, photos will still be obtained for my chart and for purposes of documentation of procedural outcomes*

Initial

12. I believe that I have been well informed. I understand that good results are expected, but the practices of medicine and surgery are not exact sciences. I understand that knowledgeable practitioners sometimes disagree as to the best methods of treatment to achieve desired results. Initial*

Initials

13. I understand that the success of the PRP procedure is dependent on my closely following all instructions. This includes but is not limited to, pre-procedure and post-procedure activities and precautions. I understand how to contact New Skin And Body Aesthetics shouldI have any concerns. I understand that I have been given their emergency contact number which I can use at any time 24 hours per day, 7 days per week. It will be given on the post procedure sheet I will take home with me. Initial*

14. This consent was read and signed while I was not under the influence of medications that might alter my mental capacity to understand its contents. Initial*

15. I certify this form has been read or it has been read to me, the blank spaces have been filled in, and I understand its contents. I was given the opportunity to ask questions about PRP. Initial*

Initial

16. I have disclosed all information regarding past and present medical conditions, current medications and known drug allergies. Initial*

Initial

17. This procedure is offered to obtain the best results for the patient, separate of any profit motive. I am aware that the practice of medicine and surgery is not an exact science and that knowledgeable practitioners sometimes disagree as to best methods of treatment to achieve desired results. I certify that no one has made any guarantee or warranty as to thefinal outcome or appearance that may be expected.*

Initial

18. I acknowledge that I am responsible for payment of these services with no fee reimbursement regardless of procedure results. I understand the fee paid is for the procedure and not for an expected result. Given that PRP does not help everyone, I understand that some patients will have PRP procedures without any benefit. I understand that payment is due the day of my procedure*

Initial

19. Unless I specifically withdraw my consent verbally or in writing, this form will also apply as consent to future PRP treatment sessions. I understand that, for my convenience, I will not be asked to complete a new PRP consent form each time I come into the office. I give consent to future sessions. Initial*

Initial

20. I have been given the opportunity by my practitioner to ask questions and all of my questions have been answered to my satisfaction. I impose the following limitations on my treatment:*

Date*

Date

Time*

Hour Minutes

AM/PM Option

I have read the above information and am aware of the risks, benefits and alternatives of PRP therapy. I have been provided with the opportunity to have questions answered and therefor give my consent to PRP injection therapy for my hair loss.

Signature of Patient*

Date*

Date

Signature of Provider*

Date*

Date

I certify that on this date I have observed the patient carefully read and sign this consent form of his/her own free will

Signature of Provider*

Date*

Date

Consent For PRP Hair Restoration

SIDE EFFECTS