PRP CONSENT FORM

PRP CONSENT FORM

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Phone/Mobile

City

Next Of Kin

Kins Contact Number (Phone/Mobile)

MEDICAL HISTORY

Do you have any bleeding disorders or are you currently taking blood-thinning medications (e.g., aspirin, anticoagulants)?

Yes

If Yes, please specify:

Do you have any active skin infections, inflammation, or open wounds in the treatment area (face or under-eye area)?

Yes

If Yes, please specify:

Have you undergone any recent facial treatments (e.g., chemical peels, microneedling, fillers, or laser treatments) in the last 2–4 weeks?

Yes

If Yes, please specify:

Do you have any chronic medical conditions such as diabetes, autoimmune disorders, or platelet-related conditions?

Yes

If Yes, please specify:

Are you currently pregnant, trying to conceive, or breastfeeding?

Yes

If Yes, please specify

Do you have any other medical conditions?

Yes

If Yes, please specify:

Procedure Description:

I understand that I am receiving Platelet-Rich Plasma (PRP) therapy for the face and/or eye area. PRP is a minimally invasive cosmetic procedure that uses components derived from my own blood to promote skin rejuvenation and healing.

During the procedure, a small amount of my blood will be drawn and placed into a centrifuge, where it is spun at high speed to separate the platelet-rich plasma from other blood components. This concentrated plasma contains growth factors that support tissue repair and collagen production.

The PRP is then carefully applied or injected into targeted areas of the skin, including the face and under-eye region. In some cases, the treatment may be combined with microneedling to enhance absorption and effectiveness.

I understand that the goal of this procedure is to improve overall skin texture, tone, elasticity, and hydration, as well as reduce the appearance of fine lines, wrinkles, dark circles, and mild skin laxity.

Results develop gradually over time as collagen production increases, and multiple sessions may be recommended for optimal outcomes.

Benefits and Risks:

I have been informed that the potential benefits of PRP therapy may include:

Improved skin texture and tone
Reduction in fine lines and wrinkles
Enhanced collagen production and skin elasticity
Brightening of the under-eye area and reduction of dark circles
Natural-looking rejuvenation using my body’s own biological material

I understand that there are potential risks and side effects associated with PRP treatment, including:

Mild discomfort during the procedure (may be managed with topical numbing cream)
Temporary redness, swelling, or tenderness at the treatment site
Minor bruising, especially in delicate areas like under the eyes
Temporary pinpoint bleeding (if microneedling is used)
Allergic reaction is extremely rare since my own blood is used
Unsatisfactory results or need for multiple sessions

I understand that serious complications are uncommon but may occur in rare cases.

Aftercare:

I agree to follow the post-treatment instructions provided by the clinician to ensure the best possible results and minimize any risks. I understand that failure to adhere to these instructions may increase the likelihood of complications.

Consent for Treatment:

I hereby consent to undergo a PRP treatment. I acknowledge that the clinician has explained the procedure, its benefits, and potential risks to me. I have had the opportunity to ask questions, and all of my concerns have been addressed to my satisfaction. I understand that the results of a PRP treatment can vary, and multiple sessions may be required for optimal results.

Release of Liability:

I release The Abram, its employees, and representatives from any liability associated with the PRP treatment, except for cases of negligence or intentional misconduct.

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Photographs and records:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Client's Initial

Receptionist's Initial

Technician's Initial

I agree that all the above information is true and accurate to the best of my knowledge

Client’s signature: