Platelet Rich Plasma Informed Consent

Purpose and Background: Platelet Rich Plasma Therapy (PRP) has been used fora  number of years in orthopedics, as well as sports and physical medicine, to assist the healing of muscle and ligament injuries, pain, and skin lesions. PRP is considered to be a safe, natural treatment because, rather than using a synthetic substance, it uses cells and growth factors from your own blood.

Results Not Guaranteed: I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I willl be completely satisfied by the outcome or that l will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that PRP treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. I understand and acknowledge that payment for the above procedure is non-refundable and that if more correction is desired, I will be responsible for purchasing additional PRP procedures to achieve the outcome I desire.

Alternatives:

• Do nothing
• Surgical intervention may be a possibility
• Injection with steroids (not long-lasting results)
• Manipulation and/or acupuncture may provide temporary pain relief
• Prescription or over the counter pain/anti-inflammatory medications

Possible Risks and Complications of Platelet Rich Plasma:

• Immediate pain at the injection site
• Stiffness in the injected joint
• Bruising
• Allergic reaction
• Infection
• Nerve or muscle injury
• Nausea/vomiting
• Dizziness or fainting
• Swelling after joint injections
• Bleeding
• Itching at injection site

Release of Liability: I release Joint Repair Clinic of MT and all staff from liability associated with this procedure except for any liability that may be imposed by the laws of the State of Montana.

Certificate of Consent to Proceed with Treatment: I understand that this treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. I understand that if I am not willing to accept all risks associated with this procedure then I should not have PRP treatment. I certify that I have read this entire consent and that I understand and agree to the information herein. I understand that to receive PRP treatment, I must comply with all stipulations outlined in this consent form; if I do not agree then I will not be able to proceed with treatment. I freely and voluntarily accept all risks associated with PRP and elect to proceed with treatment today as well as any future and ongoing treatments.

CONSENT: My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to Joint Repair Clinic of MT to perform Platelet Rich Plasma ("aka" PRP injections) to the area(s) discussed during our consultation. I have read this informed consent and certify that 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 understand that I have access to the medical provider if I have any questions regarding the treatment, both pre and post-treatment. 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. Any expense which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to, dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.