Platelet-Rich Plasma (PRP) Therapy Consultation and Consent Form

Covid-19 Screening

To ensure the safety of all parties and to stop the further spread of the Covid-19 virus, please complete the below questions as honestly and accurately as possible prior to your appointment date.

Appointment Guidance

  • If you have answered yes to any of the above questions we will be in contact as you may need to reschedule your appointment with us.
  • Please only attend at your appointment time.
  • Please ensure you are on time - if you are late this may result in your appointment being cancelled.
  • Please attend your appointment unaccompanied.
  • Please limit the personal possessions you bring with you.
  • Please wear a face mask/covering to your appointment.
  • Upon arrival please wait until you are called forward to reception.
  • Upon arrival please use the hand sanitiser provided.
  • Please maintain social distancing where possible.
  • If you experience Covid-19 symptoms after your appointment please contact us immediately.


Tap or click on the signature above to sign


Client Details


Treatment Description

In recent years, doctors have learned that the body has the ability to heal itself. Platelet-rich plasma therapy is a form of regenerative medicine that can harness those abilities and amplify the natural growth factors your body uses to heal tissue.


What is plasma and what are platelets?

Plasma is the liquid portion of whole blood. It is composed largely of water and proteins, and it provides a medium for red blood cells, white blood cells and platelets to circulate through the body. Platelets, also called thrombocytes, are blood cells that cause blood clots and other necessary growth healing functions.
Platelet activation plays a key role in the body's natural healing process.


What is platelet-rich plasma (PRP) and what are PRP injections?

Platelet-rich plasma (PRP) therapy uses injections of a concentration of a patient’s own platelets to accelerate the healing of injured tendons, ligaments, muscles and joints. In this way, PRP injections use each individual patient's own healing system to improve musculoskeletal problems.
PRP injections are prepared by taking anywhere from one to a few tubes of your own blood and running it through a centrifuge to concentrate the platelets. These activated platelets are then injected directly into your injured or diseased body tissue. This releases growth factors that stimulate and increase the number of reparative cells your body produces.

If you have any questions please do not hesitate to ask your nurse practitioner or physician.


Contraindications

 If you have ANY of the following conditions, a PRP Treatment will NOT be suitable for you. Please discuss with your nurse practitioner or physician if you are unsure of any of the mentioned conditions.

- Critical thrombocytopenia (low platelet count)
- Hypofibrinogenaemia
- Haemodynamic instability (collapse)
- Sepsis (infection)
- Acute and chronic infections
- Chronic liver disease
- Anticoagulation therapy (warfarin, dabigatran, heparin)
- A medical condition that could worsen or spread with injections, such as an active infection, a metastatic disease, or certain skin diseases
- Blood disorders and/or platelet abnormalities
- Anemic
- Pregnant or breastfeeding



Side Effects

- You 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.
- You may notice a tingling sensation while the cells are being activated.
- In rare cases skin infection may occur, which is easily treated with an antibiotic.


Consent

Please check the following to show your understanding and agreement:

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 may require a series of up to 6 sessions 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 can not be accurately anticipated. Therefore there can be no guarantee as expressed or implied either as 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.

I have answered all questions fully and to the best of my ability.

I state that I have read this form (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. I 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.

I authorize the practitioner to perform the injection of PRP (Platelet Rich Plasma) for rejuvenation.



Tap or click on the signature above to sign


SUBMIT

(disabled)