FACIAL PRP (PLATELET-RICH PLASMA) CONSENT FORM
1. Purpose of Treatment
A PRP (Platelet-Rich Plasma) facial uses a small sample of my own blood, which is processed to separate the platelet-rich plasma. This plasma is then applied or injected into my skin to support skin rejuvenation.
2. Description of the Procedure
A small amount of blood will be drawn from my arm.
The blood will be placed in a centrifuge to isolate the PRP.
The PRP will be applied to or injected into my face, depending on the technique used.
Multiple sessions may be recommended for best results.
3. Potential Benefits
Improved skin texture and tone
Reduction in fine lines
Enhanced overall skin appearance
Natural treatment using my own plasma
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4. Risks and Possible Side Effects
I understand that, as with any cosmetic procedure, risks may include:
Redness, swelling, or bruising
Temporary discomfort
Infection
Allergic reaction (rare, as PRP is from my own blood)
No guarantee of results
5. Contraindications
I confirm that I have informed the practitioner if I have:
Blood disorders
Active skin infections
Autoimmune conditions
Pregnancy or breastfeeding
Recent use of blood-thinning medication
Any other relevant medical conditions
6. Alternatives
I understand that alternative treatments exist, including microneedling without PRP, chemical peels, laser treatments, or choosing no treatment.
7. Voluntary Consent
I confirm that:
I have had the procedure explained to me.
I have had the opportunity to ask questions.
I understand the risks, benefits, and alternatives.
I am choosing to proceed voluntarily.
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8. Photography (Optional)
I consent/ do not consent (circle one) to before-and-after photographs for documentation or educational purposes.
Yes or No
Yes
No
9. Acknowledgement
By signing below, I confirm that I have read and understood this consent form and agree to receive the PRP facial treatment.
Client Name:
Date of Birth:
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Year
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Address:
Email Address:
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Phone:
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Client Signature:
Date:
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