CONSENT FOR PLATELET RICH PLASMA TOPICAL HAIR RESTORATION
Platelet Rich Plasma is known as “PRP” and is a topical treatment for hair restoration application. During the procedure, a relatively small amount of your blood will be drawn into a syringe. We will spin the blood to draw out the PRP, which we will combine with an activation agent that helps keep the PRP in place during the injection. We will make tiny incisions in your skin using a micro-needle and PRP is applied topically and/or inject PRP directly into scalp. This process will induce an inflammation response in your skin that will trigger the growth of new collagen to induce younger looking skin. PRP micro-needle are used to treat areas of hair loss. Alternative treatments include hair transplantation.
RISKS AND SIDE EFFECTS: Risks include pain, itching, bleeding, bruising and infection at the site of injection; redness; allergic reaction to the activation solution; and swelling. Additionally, some individuals may experience minimal improvement from PRP hair restoration.
TELL YOUR HEALTHCARE PROVIDER IF YOU HAVE: recent fever, cold/flu, cold sores, rashes, etc., on the treatment site; recent or planned surgery on your face, neck or chin; cosmetic treatments on your face, neck or chin; medical conditions near the treatment area; trouble swallowing; bleeding problems; if you are pregnant or plan to become pregnant; are breastfeeding or plan to breastfeed. Also, tell your provider of any medications, both prescription and over-the-counter, that you are taking, especially any blood-thinning medications.
RESULTS: Although good results are anticipated, we cannot guarantee any level of results and a poor response may occur and additional injections may be required. Also, the effect of a PRP hair restoration may diminish over time, requiring additional injections.
PREGNANCY: It is not known whether injections would harm a developing fetus or whether is excreted in human milk. It is not recommended for pregnant or nursing mothers to have PRP hair restoration.
This consent document should not be considered as all-inclusive of the possible risks or side effects of a PRP hair restoration. Please ask your healthcare provider if you have any questions regarding this information and be sure you understand the procedure and possible results before signing this form.
CONSENT FOR PRP Hair Restoration
I AgreeI authorize Elizabeth Adams, M.D., LLC and any assistants involved to perform the following procedure: PRP Hair Restoration using micro-needling and/or direct injection. I authorize the physician and staff to perform any necessary treatments or other procedures necessary in the exercise of his/her professional judgment if any unforeseen circumstances arise that require alternative treatment. I consent to the use of anesthetics and understand that all anesthetics involve potential risks and complications, injury and sometimes death. I agree that no guarantee of results has been provided to me. The above procedure has been explained to me and I understand the risks, side effects, and possible alternatives. I have had an opportunity to ask questions and my questions have been answered to my satisfaction.