I have been advised and consulted about the injection technique of platelet rich plasma used as therapy for various medical & aesthetic reasons.

I understand and voluntarily consent and authorize the following procedure: re-injection of platelet rich plasma. I understand the procedure may require follow up treatments.

I have been advised that platelet rich plasma is an established and well accepted treatment technique. The procedure requires the injection of platelet rich plasma derived from my own blood according to standard blood collection and injection techniques.

I have been advised that NO preparation is required for having the procedure under local anesthetics.

I have been informed that the procedure has been used on many patients and has been proven safe. The procedure may not completely eradicate my symptoms or complaint.

PLEASE NOTE : It is important to let the doctor know if you are on Aspirin / Anti-inflammatories,Heparin or Warfarin or Cardiac medications prior to the procedure.

I acknowledge that no guarantee has been given by anyone as to the results that I may have. I have been informed that the risks and complications of PRP injections, although extremely rare, may be:
• Immediate pain at the injection site
• Bruising
• Itching at injection site
• Nausea/vomiting
• Dizziness/fainting
• Infection
• Nerve or muscle injury
• Temporary blood sugar increase

I have been informed that having the procedure is an option.

I understand that this procedure is usually not covered by insurance and I am responsible for the total charges.

I consent to the disposal of any tissue removed and not needed after the isolation of the stem cells. I certify that I understand all the information above in its entirety, have had my questions answered, and the potential side effects explained.

As per GDPR laws, any data collected is dealt with very seriously and with extreme confidentiality.