MICRONEEDLING WITH PRP CONSENT FORM
DESCRIPTION OF TREATMENT:
This treatment involves the collection of your blood (approximately 20 ml), then your blood is spun down using a centrifuge that separate out plasma and platelet portion using the separator gel as a special filter. The PRP portion of your blood is there at the point of care to re-energize your cells into rejuvenating themselves. The product is 100% your own blood byproduct (autologous).
CONTRAINDICATIONS:
I should not have PRP treatment done if I have any of the following conditions: Skin conditions and diseases including: Facial cancer, existing or uncured. This includes Squamous Cell Carcinoma (SCC), Basal Cell Carcinoma (BCC), and melanoma, systemic cancer, chemotherapy, steroid therapy, dermatological diseases affecting the face (i.e.Porphyria), Blood disorders and platelets abnormalities, Anticoagulation therapy (i.e.Warfarin).
I have never been told that I suffer from or suspect I suffer from: Platelet dysfunction syndrome, critical thrombocytopenia, hypofibrinogenaemia, haemodynamic 1nstability, sepsis, chronic liver disease, Hepatitis or any acute or chronic infections, Melasma, Scleroderma, Collagen Vascular Disease, Clotthing Disorders, or Immunosupression.
I am not currently taking any of the following medications: Aspirin, Anti-inflammatory such as Nurofen, Votaren, Diclofenac, Naproxen etc., or Accutane (within the last 6 mths ). I am not currently taking, or haven’t recently taken (within 14 days) Vitamin E, St. John’s Wart, Garlic or Fish Oil supplements that could have a thinning effect on your blood.
SIDE EFFECTS:
I will likely experience mild to moderate swelling of the treated area, that will last 12-24 hours; ice or cold compresses can be applied to reduce swelling if required. I may notice a tingling sensation while the cells are being activated. In rare cases skin infection may occur, which is easily treated with an anti-biotic. i understand that due to the natural variation in quality of Platelet Rich Plasma results may vary between individuals. I understand that although I may see a change after my first treatment, I will require at least 3 treatments to obtain my desired outcome.
The procedure and side effects have been explained to me including alternative methods; as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee to the success or other result of the treatment. I am aware that PRP treatment is not permanent as natural degradation will occur over time.
authorize Jackie Trimby Practice Nurse to perform the injection of PRP (Platelet Rich Plasma) for rejuvenation. This consent form will be valid for up to 6 applications of PRP, after which time I may be asked to complete a new form. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner and that all blanks were filled in prior to my signature.
THIS CONSENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME IN WRITING. When completing the medical questionnaire, I have answered the personal medical history questions fully and to the best of my ability.
