PRP Consent

PRP CONSENT FORM
Platelet Rich Plasma, also known as "PRP" is an injection treatment whereby a person’s
own blood is used. This procedure is recently approved in UAE; however, PRP has been
used for over 30years. Its proven effectiveness has extended across multiple medical
specialties such as orthopedics, sports medicine, wound management, cardiovascular
surgery, maxillofacial surgery, dermatology and cosmetic surgery.
A fraction of blood is drawn from the individual patient into vacuum tubes. The tubes
with blood are spun down in a centrifuge to separate its components (RBC, PRP and
WBC). The platelet rich plasma is first separated then transferred to the PRP collection
vacuum tubes or to the PRP activation vacuum tube through close system as per the
decision of the physician. The PRP activation tubes contains 0.03ml of calcium chloride
to activate the PRP and initiate fibrin polymerization which allow the release of growth
factors from the platelets which in turn amplifies the healing process. PRP is then
injected into the area to be treated. Platelets are very small cells in your blood that are
involved in the clotting 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
clot, they release a number of enzymes to promote healing and tissue responses
including attracting stem cells 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 to 60 minutes. Generally, 2-3
treatments are advised. However, more may be indicated for some individuals. Touch
up treatment may be done once a year after the initial group of treatments to boost
and maintain the results.
PROCEDURE
 BLOOD DRAW: blood is drawn with closed system into PRP vacuum tubes to prevent
contamination.
 CENTRIFUGATION: the tubes of blood are put into a centrifuge, where the blood is
spun in order to separate the red blood cells from the PRP for 6minutes at 2800rpm or
1100g.
 TRANSFER OF PRP: transfer the PRP into PRP collection vacuum tubes or to the PRP
activation vacuum tube through close system as per the decision of Doctor.
 COLLECTION INTO SYRINGE FOR APPLICATION: transfer of PRP into syringe for

application.
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 date have been the creepy 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 would be 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 is safe for most individuals between the ages of 25-80. 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 and etc.)
3) Cancer 4) Chemotherapy treatments 5 ) Severe metabolic and systemic disorders 6)
Abnormal platelet function (blood disorders, i.e. Hemodynamic 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, 11) pregnant or breastfeeding, 12) Other health
issues (unknown)
In case, that I have known and unknown cases of such contraindication and would like
to proceed with the procedure, I will be solely responsible for the consequence of the
treatment.
RISK AND COMPLICATIONS:
I have been informed that some of the side Effects of Platelet Rich Plasma include: 1)
Pain and itching 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; 6) Nausea /vomiting; 7)
Dizziness or fainting; 8) Temporary blood sugar increase 9)scarring and crusting
10)onset of herpes or acne 11)burning and blistering 12) unsatisfactory cosmetic result
13)extrusion, swelling and transient skin discoloration. Picking the area may result in
adverse reactions and affect the results of the treatments there strictly prohibited.
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.
CONFIDENTIALITY: I authorize hereby taking my photographs before, during and

after treatment for my medical records. I also authorize my physician the ongoing and
unrestricted use of my photographs and electronic images for general information,
education, scientific, medical and promotional purposes with complete confidentiality of
my identity.
RIGHT TO REFUSE TREATMENT / PROCEDURE: Patient has full right to refuse the
treatment.
ALTERNATIVES to PRP:
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
By signing this form, you confirm and consent to the following:
1. I hereby grant authority to the physician/practitioner to perform Platelet Rich

Plasma “aka" PRP injections to area(s) discussed during our consultation.
2. All of my questions have been answered to my satisfaction and I consent to the

terms of this agreement.
3. I agree to follow all safety precautions and instructions after the treatment.
4. 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.
5. I agree to administer a topical anesthetic prior to treatment if required for pain

relief.
6. It has been discussed to me by my therapist / doctor the procedure, potential

side effects of the treatment being idiosyncratic reactions (reactions specific to
an individual), risks and contraindications and alternatives of the treatment.
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
agree that if I should have any questions or concerns regarding my treatment/results I
will notify this immediately so that timely follow-up and intervention can be provided.
Having been apprised of all the above, I have signed this Consent Form and authorize
the subject treatment.
Patient Full Name & Signature: _________________________ Date & Time: ___________________
Therapist Name & Signature: __________________________ Date & Time: ___________________

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PRP CONSENT FORM

 COLLECTION INTO SYRINGE FOR APPLICATION: transfer of PRP into syringe for

RISK AND COMPLICATIONS:

CONFIDENTIALITY: I authorize hereby taking my photographs before, during and

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

By signing this form, you confirm and consent to the following:

1. I hereby grant authority to the physician/practitioner to perform Platelet Rich

2. All of my questions have been answered to my satisfaction and I consent to the

4. I understand that medicine is not an exact science and acknowledge that no

5. I agree to administer a topical anesthetic prior to treatment if required for pain

6. It has been discussed to me by my therapist / doctor the procedure, potential

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