• XPRESS HEALTH URGENT CARE / EXPRESS HEALTH URGENT CARE / BERKLEY URGENT CARE Platelet-Rich Plasma (PRP) Treatment Consent and Authorization

  • Patient Information

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • DESCRIPTION OF PROCEDURE
    Platelet-Rich Plasma (PRP) therapy is a regenerative treatment that involves drawing a sample of your blood, processing it to concentrate platelets and growth factors, and injecting the platelet-rich plasma into the designated treatment area. PRP may be used for hair restoration, tendon and ligament injuries, joint pain, arthritis, muscle injuries, and other conditions deemed appropriate by your healthcare provider.


    POTENTIAL BENEFITS
    • Reduction in pain and inflammation
    • Improved healing and tissue repair
    • Improved joint or soft tissue function
    • Hair growth stimulation in appropriate candidates
    • Delayed need for more invasive treatments
    No specific outcome or result can be guaranteed.


    RISKS AND POSSIBLE COMPLICATIONS
    • Pain or discomfort during or after injection
    • Bruising
    • Swelling
    • Bleeding
    • Temporary worsening of symptoms
    • Infection
    • Nerve irritation or injury
    • Tissue damage
    • Allergic reaction to materials used during the procedure
    • Scar formation
    • Failure to improve symptoms
    • Need for additional procedures or treatments


    CONTRAINDICATIONS
    Please inform your provider if you have any of the following:
    • Active infection
    • Skin infection at the treatment site
    • Bleeding disorder
    • Low platelet count
    • Severe anemia
    • Active cancer or ongoing cancer treatment
    • Uncontrolled diabetes
    • Severe liver disease

    • Pregnancy or breastfeeding
    • Current use of anticoagulants or blood thinners

    POST-PROCEDURE INSTRUCTIONS
    • Avoid strenuous activity for 24-48 hours unless otherwise directed.
    • Avoid anti-inflammatory medications (NSAIDs) for 7-14 days after treatment unless instructed otherwise.
    • Tylenol may be used if pain relief is needed unless contraindicated.
    • Follow all provider instructions and attend follow-up appointments.


    WHEN TO SEEK MEDICAL ATTENTION
    Contact the clinic or seek emergency care for:
    • Fever greater than 100.4°F
    • Increasing redness, warmth, or swelling
    • Drainage or signs of infection
    • Severe or worsening pain
    • Excessive bleeding
    • Shortness of breath
    • Chest pain
    • Allergic reaction or any concerning symptoms


    ALTERNATIVE TREATMENT OPTIONS
    Alternatives may include observation, physical therapy, oral medications, corticosteroid injections, hyaluronic acid injections, surgery, or other provider-recommended treatments.

    ACKNOWLEDGMENT AND CONSENT
    I acknowledge that the nature and purpose of PRP therapy have been explained to me. I understand the risks, benefits, alternatives, and limitations of treatment. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. No guarantee has been made regarding the outcome of treatment. I voluntarily consent to undergo PRP therapy.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • CLINIC USE ONLY

  • Should be Empty: