Platelet Rich Plasma (PRP) Treatment Sheet

Platelet Rich Plasma (PRP) Treatment Sheet
First Name*
Last Name*
Email*
Patient Email on file
Date*

MonthDayYear
Date
Provider*
Anesthesia*
Treatment #*
Age*
PRP Assistant*
Allergies*
Facility*
Procedure*
Previous Exposure to Bovine Thrombin?*

YesNoUnknown
Checklist*

Visual Inspection of hardware/electricalOperational modes working correctlyFloading Shelf movement verifiedSupplies availability verifiedDisposeable(s) sterility intact, no defect notedLabel Applied (patient & products)System Component and backup availableSyringe(s) Plunger movement verifiedPatient Consent Form completed and in chartBlood borne Pathogens/Sterile procedures followed
Processing Information
Venous Blood Drawn*
Draw Site*
Phlebotomy done by*
Blood draw by*
Product Volume*
Applications
PRP vol. used*
PRP application site(s)*
Conclusions
Conclusion*

PRP Record CompleteEquipment Cleaned/ReadyDisposal per biohazard PolicyAssistance offered to Nurse and/or staff
EQUIPMENT/SUPPLIES:
-0-15*
Microneedling tip: Other*
LOT NUMBERS (1)*
LOT NUMBERS (2)*
LOT NUMBERS (3)*
Not Applicable*
COMMENTS*
PROVIDER SIGNATURE*

Clear
Should be Empty:

Processing Information