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CONSENT FOR PRP Hair Restoration

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 Agree
I 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.

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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