yakimahealth.com - PRP Injection Health History and Consent Form

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

1. Do you have any of the following medical conditions?

I, (patient name) , understand and consent to the Platelet-Rich Plasma (PRP) Injection procedure. I have been informed of the nature of the treatment, its purpose, and potential benefits and risks, which include but are not limited to:

Benefits: Possible reduction of pain, inflammation, or improvement in healing.
Risks and Side Effects: Pain, swelling, infection, allergic reactions, nerve damage, or temporary worsening of symptoms.

I acknowledge the following:

PRP Injection is a minimally invasive procedure, and there is no guarantee of specific outcomes.
Alternative treatments have been explained, including physical therapy, medications, or surgery.
I have had the opportunity to ask questions and am satisfied with the information provided.

Consent to Treatment
By signing below, I authorize Susan Bell, ARNP at HealthWithin Wellness Center to perform the PRP Injection procedure. I consent to photographs and/or videos for medical records as needed.

PRP Injection Health History and Consent Form

Patient Information

Medical History

Consent for PRP Injection Procedure