PLATELET RICH PLASMA (PRP) CONSENT FORM

Platelet Rich Plasma, or PRP, is blood plasma with concentrated platelets. The concentrated platelets found in PRP contain reservoirs of bioactive proteins, including growth factors that are vital to initiate and accelerate tissue repair and regeneration. The procedure involves the collection of your own blood (10-20ml), then your blood is spun down using a centrifuge to separate out the plasma and platelet portion. The PRP portion is then injected back into your skin to stimulate collagen formation and re-energize your cells into rejuvenating themselves.

CONTRAINDICATIONS

I understand that I should NOT have the PRP treatment done if I have:

An autoimmune disease or connective tissue disorders (e.g., lupus)
Coagulation / bleeding / platelet disorder
Anticoagulation (blood thinning) therapy
Skin or systemic cancer – present and past
Accutane / Isotretinoin treatment within the past 6 months
Active cold sores / herpes or any other skin infection at the site of treatment
History of keloid formation or excessive scarring
I have informed the doctor performing the procedure of my past medical history and all medications and food supplements I use as they may interfere with the treatment.

RISKS AND COMPLICATIONS

Short term discomfort
Redness and swelling
Pin-point bleeding and mild bruising
Rarely infection and scarring

ALTERNATIVES TO PRP

PRP performed is purely for cosmetic reasons, therefore it is not essential to have it done. There are other rejuvenating procedures available that can be done instead or in combination with PRP. They include: radiofrequency devices, botox, fillers, fractional resurfacing lasers, chemical peels and mesotherapy.

PREGNANCY

I understand that this treatment is NOT recommended for pregnant and breastfeeding women and I confirm I am not pregnant or breastfeeding.

PAYMENT

I agree to pay the exact value for the above-mentioned procedure, and I understand that there will be no refund for any performed services.

RESULTS

Due to the nature of this treatment, the exact results cannot be predicted, and I acknowledge that no guarantees have been made to me as to the results that may be obtained. I further understand that no promises of permanence have been made to me.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

Pre and post treatment instructions have been explained to me.
I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
I must notify the clinician if my medical history changes prior to subsequent treatments.
I consent to clinical photographs being taken of my treated areas for my personal health record only.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE CLINIC, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature