PRP PRF informed consent

Informed Consent for PRP/PRF Procedures

Youthful Reflections, LLC 3 Geyser St., Suite 7 Ennis, MT 59729

(406) 925-3036 rnjordanstone@youthfulreflectionsmt.com

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Platelet Rich Plasma or Platelet Rich Fibrin, also known as PRP/PRF, is derived from the patient's own blood in the following manner. A fraction of blood (20cc) is drawn from the individual patient into a syringe. This is a relatively small amount compared to blood donation. The blood is spun in a special centrifuge to separate its components (Red Blood Cells, Platelet Rich Plasma, Platelet Poor Plasma and White Blood Cells The Platelet Rich Plasma containing monocytes and various plasma proteins are collected into a syringe. The PRP is then injected within the next few minutes as a medical intervention. As the platelets organize in the clot, they release enzymes to promote healing and tissue responses including attracting stem cells and growth factors to repair damaged tissue and cause regeneration and rejuvenation.

The full procedure may take between 20-45 minutes. Often 3-4 treatments are advised, however, more or less may be necessary for some individuals. It is often recommended that treatments be done once a year after the initial group of treatments to continue regeneration and maintain or enhance the results.

PRP'S safety has been established for over 20 years for its wound healing properties and its theoretical effectiveness has extended across multiple medical specialties including cardiovascular surgery, orthopedics, sports medicine, podiatry, ENT, neurosurgery, dental and maxillofacial surgery (dental implants and sinus elevations), urology, dermatology (chronic wound healing), ophthalmology, and cosmetic surgery.

BENEFITS of PRP: PRP is autologous (using your own blood) therefore eliminating allergy potential. PRP has been shown to have tissue regenerating effects. Other benefits include: minimal down time, safe with minimal risk, short recovery time, and no general anesthesia is required.

CONTRAINDICATIONS: PRP use is safe for most individuals between the ages of 18-80. There are very few contraindications, however, patients with the following conditions are not candidates:

1. Pregnancy or Lactation

2. Acute and Chronic Infections

3. Skin diseases (i.e. SLE, porphyria, allergies)

5. Chemotherapy treatments

6. Severe metabolic and systemic disorders

7. Abnormal platelet function (blood disorders, i.e. Hemodynamic Instability, Hypofibrinogenemia, Critical Thrombocytopenia)

8. Chronic Liver Disease

9. Anticoagulation therapy (Coumadin, Warfarin, Plavix, Aspirin, Lovenox, Eliquis)

10. Underlying Sepsis

11. Systemic use of corticosteroids within two weeks of procedure

I do NOT have any of the CONTRAINDICATIONS listed above.

RISKS & COMPLICATIONS: Some of the Potential Side Effects of Platelet Rich Plasma include:

1) Pain at the injection site or microneedling sites

2) Bleeding, Bruising and/or Infection as with any type of injection or microneedling

3) Short lasting pinkness/redness (flushing) of the skin

4) Allergic reaction to the solution, an/or topical anesthetic

5) Injury to a nerve and/or muscle as with any type of injection

6) Itching and Swelling at the injection site(s)

7) Minimal or no effect from the treatment

I UNDERSTAND the above risks and complications.

ALTERNATIVES to PRP: Alternatives to PRP elective procedures are:

1. Do Nothing

2. Surgical intervention

3. Administration of approved medications

4. Laser or other ablative technology

I UNDERSTAND the above Alternatives to PRP.

Procedure specific risks in addition to those stated above include for PRP: No effect at all, hair loss, severe headache, injections site infection, hematoma, redness, discoloration, swelling that may extend into the surrounding tissues that may last several days.

I acknowledge the above are risks of receiving PRP treatment through microneedling or injection.

Procedure Specific Risks in addition to those stated above include for FACIAL PRP: No effect at all, injections site infection / redness, swelling, and discoloration, swelling that may extend into the surrounding tissues that may last several days.

I acknowledge that the following is a risk of Scalp PRPI am not having Facial PRP done

I grant Youthful Reflections, LLC, its representatives, and employees the right to take photographs or videos of me in connection with receiving any treatments from Youthful Reflections. I authorize Youthful Reflections, its assignees, and transferees to copyright, use, and publish the same in print or electronically. I agree that Youthful Reflections may use such photographs or videos of me with or without my name and for any lawful purpose, including for example such purposed as publicly, illustration, advertising, social media and web content.

I agreeI do NOT agree

I give Youthful Reflections my permission to use all photos and videos taken of me to use on social media and/or for advertising.

YesNo

RESULTS: I understand that due to the natural variation in quality of Platelet rich plasma, results will vary between individuals. I understand that although I may see a change after my first treatment; I may require multiple sessions to obtain my desired outcome. It is recommended that once treatment goals are accomplished, an annual PRP procedure is likely necessary to maintain results.

CONSENT: My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to the physician/practitioner to perform Platelet Rich Plasma "aka" PRP injections or microneedling to area(s) discussed during our consultation, for the purpose of rejuvenation and regeneration of affected tissue. I have read this informed consent and certify I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them.

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. I also understand this procedure is "elective" and not covered by insurance and that payment is my responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.

I hereby give my voluntary consent to this PRP procedure and release Jordan Stone, RN BSN and her business staff from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I agree that if I should have any questions or concerns regarding my treatment, I will notify this office and/or provider immediately so that timely follow-up and intervention can be provided.

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