MD MEDICAL PRF APPLICATION

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We are going to be holding clinics for a new treatment, Platelet Rich Fibrin which is an injectable rejuvenation treatment which is derived from your own blood.

PRF, or Platelet-Rich Fibrin, is a second generation platelet concentrate derived from a patients own blood. It’s used to promote healing & tissue regeneration for various medical & aesthetic treatments. It can also be used to improve the skin quality prior to other treatments like dermal filler to improve the cosmetic outcome, for example under the eyes where skin is delicate & thin.

As this is a new treatment we are keen to treat across various age groups and treatment indications to get feedback on the results and also a greater understanding of how this can work with other treatments and treatment sessions required.

We are looking for people to have this treatment at 50% of the cost who would be prepared to offer feedback and also be happy to have photographs and or video of the treatment for patient education, website and social media.

Please complete the form with your preferences and we will contact you to participate in the treatment sessions.
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Name* This field is required.
First Name
Last Name
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Date of Birth * This field is required.
Date
Day
Month
Year
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Phone Number * This field is required.
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Email* This field is required.
example@example.com
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Medical History* This field is required.This will assess your suitability for treatment, and will not necessarily rule out treatment but we may need to make adjustments to your treatment plan.
Are you Pregnant, Breast Feeding or Receiving IVF Treatment
Allergies
Heart Disease
Cancer in Previous 5 Years
Angina
Arthritis
Diabetes
Thyroid Disease/Problems
HIV or Hepatitis
Autoimmune Disease
Convulsions
Asthma or Bronchitis
High or Low Blood Pressure
Skin Disease, Herpes or Acne
Stomach Ulcer or Colitis
Facial Cold Sores
Keloid or Hypertrophic Scarring
Depression or Anxiety
Body Dysmorphic Disorder
Mental Health Diagnosis
Anything else you think is important for us to know
Not Applicable
Other
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Medical History Information Please provide us with any details you think could be relevant
Huge
Large
Normal
Small
Ok
Ok
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Do you have a phobia of needles, particularly when you have your blood taken ?* This field is required.
YESNO
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Have you ever become unwell or fainted after bloods are taken ?* This field is required.
YESNO
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Do Practitioners have difficulty taking your blood ?* This field is required.
YESNO
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Treatment Preferences* This field is required.Please select all relevant
Undereye Wrinkles, or Hollows
Small Area Facial Rejuvenation eg around eye area, forehead etc
Full Face Rejuvenation
Neck Rejuvenation
Chest Rejuvenation
Hand Rejuvenation
Scar Treatment
Other (please indicate below)
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If you have selected other please provide more information
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Large
Normal
Small
Ok
Ok
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Photograph Consent* This field is required.Please note that consent to printed publications cannot be withdrawn from any current printed materials only for future printed documents.
Medical Records
Consultation Only
Website
Social Media
Printed Publication
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Video ConsentPlease indicate
Consultation
Website
Social Media
I do not consent to video
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Please indicate that you will complete the post treatment questionnaire so we can process and review feedback regarding the treatment process and the treatment outcomes. This may include a review published on the website and or social media.Please note that you do not have to leave your full name on the review sites.
YESNO
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Treatment Day PreferenceWe will contact you to book your appointment slot once we have confirmed dates
Friday
Sunday
10AM - 2PM
3 - 7PM
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SignatureI confirm that the information provided is accurate and understand that any omission of relevant information or false information may result in my treatment being discontinued.
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