PRP Consent Form

  • PRP Informed Consent

    Platelet Rich Plasma, also known as "PRP" is an injection treatment whereby a person’s own blood is used. A fraction of blood (20cc) is drawn up from the individual patient into a syringe. This is a relatively small amount compared to blood donation which can remove 500cc. The blood is spun i n a special centrifuge to separate its components (Red Blood Cells, Platelet Rich Plasma, Platelet Poor Plasma and Buffy Coat). The Platelet Rich Plasma and Buffy Coat is first separated and combined then activated with a small amount of calcium chloride which acts as an activation agent and scaffold to keep the PRP where the injector intends to treat. Platelets are very small cells in your blood that are involved in the clotting and healing process. When PRP is injected into the damaged area it causes a mild inflammation that triggers the healing cascade. As the platelets organize in the treatment area they release a number of enzymes to promote healing and tissue responses including attracting stem cells and growth factors to repair the damaged area. As a result new collagen begins to develop. As the collagen matures it begins to shrink causing the tightening and strengthening of the damaged area. When treating injured or sun and time damaged tissue, they can induce a remodeling of the tissue to a healthier and younger state. The full procedure takes approximately 45 minutes to an hour. Generally 2-3 treatments are advised, however, more may be necessary for some individuals. Touch up treatments may be done once a year after the initial group of treatments to boost and maintain the results.

     

    PRP'S SAFETY has been established for over 20 years for its wound healing properties and it's proven effectiveness has extended across multiple medical specialties including cardiovascular surgery, orthopedics, sports medicine, podiatry, ENT, neurosurgery, dental and maxillofacial surgery (dental implants and sinus elevations), urology, dermatology (chronic wound healing), and ophthalmology, cosmetic surgery. PRP's emergence into aesthetics and skin rejuvenation began i n 2004 in Europe, Asia, Australia, and South America in countries such as The United Kingdom, Japan, Spain, Portugal, Switzerland and Argentina to name a few. Areas typically treated for aesthetic purposes and skin rejuvenation include: Crinkling skin around the eyes, cheeks and midface, neck, jaw-line, chest and décolletage, back of hands and arms, lips, and to stimulate hair growth on scalp. Almost all skin tones show that PRP is safe and effective because your own enriched plasma is used.

     

    BENEFITS of PRP: Along with the benefit of using your own tissue therefore virtually eliminating allergies, there is the added intrigue of mobilizing your own stem cells for your benefit. PRP has been shown to have overall rejuvenating effects on the skin including: improving skin texture, thickness, fine lines and wrinkles, increasing volume via the increased production of collagen and Elastin, and by diminishing and improving the appearance of scars. The most dramatic results to dat e have been the crepey skin problems in areas such as under the eyes, neck, and décolletage. It is not designed to replace cosmetic surgery as there are some cases where t hose procedures wo u l d b e more appropriate. Other benefits include: minimal down time, safe with minimal risk, short recovery time, natural looking results; no general anesthesia is required.

     

    CONTRAINDICATIONS: PRP used for aesthetic procedures is safe for most individuals between the ages of 18-80. Parental Consent required .for patients under 18. There are very few contraindications, however, patients with the following conditions are not candidates: 1) Acute and Chronic Infections 2) Skin diseases (i.e. SLE, porphyria, allergies) 3) Cancer 4) Chemotherapy treatments 5 ) Severe metabolic and systemic disorders 6) Abnormal platelet function (blood disorders, i.e. Haemodynamic Instability, Hypofibrinogenemia, Critical Thrombocytopenia) 7) Chronic Liver Pathology 8) Anti-coagulation therapy, 9) Underlying Sepsis and 10) Systemic use of corticosteroids within two weeks of the procedure.

     

    RISKS & COMPLICATIONS: Some of the Potential Side Effects of Platelet Rich Plasma include: 1) Pain at the injection site; 2) Bleeding, Bruising and/or Infection as with any type of injection; 3) Short lasting pinkness/redness (flushing) of the skin; 4) Allergic reaction to the solution; 5) Injury to a nerve and/or muscle as with any type of injection; 6) Itching at the injection site(s); 7) Nausea /vomiting; ( The following are possible with any simple injection and not specific to PRP Therapy).8) Dizziness or fainting; 9) Temporary blood sugar increase; 10) Swelling; 11) Minimal effect from the treatment.

     

    ALTERNATIVES to PRP: Alternatives to PRP are: 1) Do Nothing; 2) Surgical intervention may be a possibility; 3) Injections with neurotoxins; 4) Injections of dermal filling agents; 5) Laser & light based treatments like Pulsed Light; 6) chemical peels.

     

    RESULTS: Results are generally visible at 4 weeks and continue to improve gradually over ensuing months (3-6) with improvement in texture and tone. Advanced wrinkling cannot be reversed and only a minimal improvement is predictable in persons with drug, alcohol, and tobacco usage. Severe scarring may not respond. Current data shows results may last 18·24 months. Of course all individuals are different so there will be variations from one person to the next.

     

    PHOTOGRAPHS: I authorize the taking of clinical photographs and their use for scientific and educational publications and presentations. I understand my identity will be protected.

     

    CONSENT: My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to the physician/practitioner to perform Platelet Rich Plasma “aka" PRP injections to area(s) discussed during our consultation, for the purpose of aesthetic enhancement and skin rejuvenation. I have read this informed consent and certify I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them. I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment. I also understand this procedure is "elective" and not covered by insurance and that payment is my responsibility. Any expenses which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.

    I hereby give my voluntary consent to this PRP procedure and release the clinic, its medical staff, and specific technicians from liability associated with the procedure. I certify that l am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I agree that if I should have any questions or concerns regarding my treatment results I will notify this office and/or the provider immediately so that timely follow-up and intervention can be provided.

     

    BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.

     

    PLEASE SIGN YOUR FULL NAME BELOW IF YOU AGREE

  • I have read and agree with all the above statements in this consent form.
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