SIGNATURE PAGE
CONSENT FOR TREATMENT
- I hereby give consent to Beauty Shots, PLLC to perform Platelet-rich-plasma (PRP) and/orPlatelet-rich-fibrin (PRF) injection treatment, I also consent to any other healthcare services during the procedurethat may become medically reasonable and necessary within the reasonable judgement of a healthcareprofessional. This includes, but is not limited to, the administration of anesthetics necessary to perform PRP/PRFinjections.
- I have declared that I have allergies on my health history intake form.
- I have declared that I take the following medications on my health history intake form.
- I understand that PRP/PRF can be used to treat hair loss. I fully understand the results that I mayreasonably expect. I understand that not all patients get improvement.
- I declare I do not have any of the following conditions which might otherwise not make me a candidate:current infections, skin diseases such as lupus or porphyria, current cancer, current chemotherapy treatments,severe metabolic or systemic disorders, liver disease, abnormal platelet function (blood disorders), anticoagulationtherapy, current use of corticosteroids, steroid injections in my scalp in the last month.
- An explanation of the procedure has been given to me. I understand that blood will be drawn from a veinin my arm. That blood will then be placed in a centrifuge machine to be spun down in order to concentrate theplatelets, and then injected back into my skin. I understand the local anesthetic medications will be given to reducethe discomfort of the PRP/PRF injections.
- I am aware of the pros, cons, and alternatives to PRP/PRF injections. I have the option of doing nothing,wearing a wig or hairpiece, using prescription medicines, having plastic surgery, or possibly having a hair transplantsurgery. A combination of the above is also possible. I understand that the PRP/PRF injection procedure is an“elective” procedure. If I do not have PRP/PRF injections, I will not experience harm or negative consequences formy body other than potentially losing more hair.
- I understand that hair loss is sometimes continuous throughout life for some people. I understand thatadditional PRP injection procedures may be needed and that some individuals would expect 1-3 sessions per year.
- I consent to and authorize the performance of PRP injections by Beauty Shots, PLLC nursepractitioners.
- I consent to having my photos taken. These include pre-operative (“before”) photos, photos during theprocedure, and post-operative (“after”) photos. I understand these photos will not reveal my identity. I giveconsent to Beauty Shots, PLLC to use these photos for advertising purposes, which may include brochures,websites, and use during preoperative consultations. I understand that I may withdraw consent by stating “noconsent for sharing photos” below my signature. However, photos will still be obtained for charting and for thepurposes of documenting outcomes.
- I believe that I have been well informed. I understand that good results are expected, but theprocedures are not exact sciences.
- The consent was read and signed while I was not under the influence of medications that might alter mymental capacity to understand its contents.
- I certify this form has been read or it has been read to me, the blank spaces have been filled in, and Iunderstand its contents. I was given the opportunity to ask questions about PRP/PRF.
- I have disclosed all information regarding past and present medical conditions, current medications,and known drug allergies. This information is necessary so that the proper medical treatment is given at all timesduring the procedure.
- I acknowledge that I am responsible for payment of these services with no fee reimbursementregardless of procedure results. I understand the fee pain is for the procedure and not for an expected result. Iunderstand that payment is due the day of my procedure.
- I have been given the opportunity to ask questions, and all of my questions have been answered to my
POTENTIAL SIDE EFFECTS
- Minor Discomfort (Pin prick sensation) from blood draw
- Dizziness and feeling faint (rare)
- A temporary headache
- Redness in the scalp for 2-4 days
- Swelling in the forehead and around the eyes. There may rarely be swelling discoloration and bruising associated with the procedure.
- Hair loss (Temporary) in the existing hair. This is often termed "shock loss".
- Infection (rare)
- Itching at the injection sites
- Minor bleeding and bruising at the sites of injections
- Injury to nerve during blood draw (very rare)
HIPAA Authorization and Acknowledgement for Open Setting Communication
As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present.
To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:
Acknowledgement of an open setting environment
I understand that:
- Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area.
- Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.
- I am not required to have any personal health discussions in an open setting.
Client Rights
- I understand that I may change my preference at any time by informing a staff member.
- I understand that my choice will not affect my care or access to services in any way.