• PRP Injection Health History and Consent Form

  • Patient Information

  •  - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical History

    Please answer the following questions. Check "Yes" or "No" and provide additional information as needed.

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

  • Blood Disorders (e.g., anemia, clotting disorders)
  • Cancer
  • Diabetes
  • Heart Disease
  • Autoimmune Disorders
  • Allergies (including drug allergies)
  • 2. Do you currently take any medications, including blood thinners, supplements, or herbal remedies?
  • 3. Have you had any recent surgeries or hospitalizations?
  • 4. Have you ever had a PRP injection or other regenerative treatments?
  • 5. Do you currently smoke or use tobacco products?
  • 6. Are you pregnant or breastfeeding?
  • 7. Do you have any history of infections, especially around the area to be treated?

  • Consent for PRP Injection Procedure

  • I,  , 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:

    1. PRP Injection is a minimally invasive procedure, and there is no guarantee of specific outcomes.
    2. Alternative treatments have been explained, including physical therapy, medications, or surgery.
    3. 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.

  •  - -
  • Should be Empty: