Platelet Rich Plasma (PRP) Treatment Sheet
First Name
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Last Name
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Email
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Patient Email on file
Date
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-
Month
-
Day
Year
Date
Provider
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Anesthesia
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Treatment #
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Age
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PRP Assistant
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Allergies
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Facility
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Procedure
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Previous Exposure to Bovine Thrombin?
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Yes
No
Unknown
Checklist
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Visual Inspection of hardware/electrical
Operational modes working correctly
Floading Shelf movement verified
Supplies availability verified
Disposeable(s) sterility intact, no defect noted
Label Applied (patient & products)
System Component and backup available
Syringe(s) Plunger movement verified
Patient Consent Form completed and in chart
Blood borne Pathogens/Sterile procedures followed
Processing Information
Venous Blood Drawn
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Draw Site
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Phlebotomy done by
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Blood draw by
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Product Volume
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Applications
PRP vol. used
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PRP application site(s)
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Conclusions
Conclusion
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PRP Record Complete
Equipment Cleaned/Ready
Disposal per biohazard Policy
Assistance offered to Nurse and/or staff
EQUIPMENT/SUPPLIES:
-0-15
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Microneedling tip: Other
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LOT NUMBERS (1)
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LOT NUMBERS (2)
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LOT NUMBERS (3)
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Not Applicable
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COMMENTS
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PROVIDER SIGNATURE
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