PRP Consultation/Consent Form | Aesthetics Forms Portal

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

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Do any of the following apply to you? Please tick all that apply. *

Low platelet count Hypofibrinogenaemia Haemodynamic instability (collapse) Sepsis (infection) Acute and chronic infections Chronic liver disease Anticoagulation therapy Anemic

Do you have any other medical conditions? *

Please list: *

Are you currently (or possibly may be) pregnant? *

Are you currently taking, or have you recently taken (within last 14 days) any of the following medications: Aspirin, Anti-inflammatory (such as Nurofen, Votaren, Diclofenac, Naproxen etc.), St. John’s Wort, Garlic, Vitamin E? *

Please specify: *

Do you have any allergies/intolerances to cow products? The reason for this question is you could experience an allergic reaction if the platelet-rich plasma is combined with an additive called bovine thrombin, which is derived from cows. *

Have you recently been unwell? *

Which of the following were you unwell with? *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

What are your skin concerns? *

What are your goals and expectations of the treatment? *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

Do you have any tattoos? *

Please list location(s) and size(s): *

Tanning History (Direct sun, Self-tanners, Spray tans etc.). Please list and include last date of use: *

Have you previously had any laser treatment? *

Previous Laser Treatment(s) - If known, please specify date, number of treatments, frequency, response to treatment, device used: *

Do you use sunscreen? *

Do you smoke? *

Treatment Information

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.

Possible Side Effects

The PRP treatment is moderately uncomfortable. A numbing cream can be applied to the skin approximately 30-45 minutes before treatment begins.

After the PRP procedure, the skin may experience:
• Redness & flushing - should decrease over a 24-hour period
• Swelling & pain – should decrease within 3-4 days
• Tenderness, stinging, itching
• Some pinpoint bleeding
• Tightness

These sensations will usually typically resolve within hours and many people are able to return to their normal activities the same or next day. Some people may react differently and may experience these reactions for longer. However, they gradually subside over the next 3-4 days as the skin returns to normal.

There is a small risk of side effects causing the skin to turn very red, blister, swell, peel and later scab and crust. In severe cases infection and ulceration may result, although this is not expected to occur due to the sterility of the needles/cannula used and the minimally invasive nature of the them.

PRP therapy procedure may cause areas of bruising although this would not normally be expected to occur, the eye contour being the area at most risk. Any such bruising will be temporary. If you are taking any medication or dietary supplements that can affect platelet function and bleeding time, the severity and period of bruising can be extended, also the presence of petechiae (small red or purple spots beneath the skin) may be observed.

Aftercare

Immediately after PRP injection

Platelet rich plasma (PRP) works over about 6 weeks to stimulate healing. It is important to give it a chance to work so follow these directions closely.
Keep your injection site clean, dry and covered with a plaster/bandage the day of your procedure. You may shower at any time. You may experience some localized swelling or bruising at the injection site that may take 3-7 days to resolve.
Avoid ice to the injection site / joint if possible. Some swelling is normal and part of the inflammation/healing process.
About 1 out of 20 patients will experience a post-injection flare due to your immune system being hyper-stimulated. This may cause significant pain and swelling and typically resolves in just a few days. If needed due to swelling or intense pain you may apply ice to the injection site / joint for 20 minutes every 2-3 hours. You might also need to take pain medication such as Paracetamol.
Do not use any prescription, or over the counter, anti-inflammatory medicines (such as Ibuprofen) for 4 days before AND for 7 days after the procedure. Ideally, we would like you to avoid the use of these medications for 6 weeks after your procedure.
Aspirin is a weak anti-inflammatory so does not interfere as much with the PRP process. If possible, stop aspirin unless it is needed for heart or other conditions.
Contact your practitioner if you develop excess pain, drainage from the injection site, bleeding, or fever, if another physician would like to put you on a new medication or if you are not sure if a medication should be taken.
You may drive home from the procedure if you had an upper extremity injection. It is strongly recommended that if you have a lower extremity procedure, you have someone drive you home.

Activity after PRP injection

For 2-3 days after your injection you should rest and avoid all activity other than minimal daily living requirements (bathing, dressing, cooking, etc). Avoid much walking if injected in the hip, knee, ankle or foot. Use crutches if you can’t walk without discomfort.
For 1-2 weeks after your injection avoid strenuous activity. For upper extremity procedures such as injections into the shoulder, elbow or wrist do not do any repetitive motion, lifting, pulling, pushing, or grasping with the arm. For lower extremity procedures such as injections into the hip, thigh, knee, ankle, or foot avoid prolonged walks, hikes, or running.
After 2 weeks return to normal activity but avoid things that cause increased pain in the injected areas.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

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

Client Signature: *

Tap or click on the signature above to sign