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Platelet Rich Plasma Therapy (PRP)/Micro needling: Patient Consent for Treatment

Thank you for choosing Dr. Dustin Moffitt at Body and Soul, LLC. In our ongoing efforts to provide you with the best possible service, we ask that you carefully review this consent form and ask all questions necessary to help you fully understand it.

A. Purpose and Background: Platelet Rich Plasma Therapy (PRP) has been used for a number of years in orthopedics and sports medicine, to treat muscle and ligament injuries, pain problems, and skin lesions. Due to the success of PRP in medicine, the procedure was then developed into an anti-aging treatment designed to induce new collagen production, reduce wrinkles, and diminish the visible signs of aging by growing new healthy tissue. PRP is considered to be a safe, natural treatment because rather than using a synthetic substance, it uses cells and growth factors from your own blood to slow and even reverse the aging process for a more youthful and radiant appearance. Collagen is what gives skin a firm, youthful appearance. As we age, less collagen is produced, causing sagging, wrinkles and soft tissue depressions in the skin. Once injected under the skin or applied topically onto the surface of the skin, PRP therapy counteracts aging by stimulating new collagen production in the exact areas of concern where we want the skin to repair and rejuvenate itself.  PRP can be used on the face, neck, décolletage, and hands. The number of treatments needed varies per patient. We recommend 1-3 treatments administered at four-week intervals until the desired result is achieved, followed by 1-2 maintenance treatments per year. While some result is visible immediately at the time of treatment, there is usually a return to baseline in 3-5 days as the PRP is absorbed back into the body prior to the complete action of the cellular regenerative process. Most patients see improvement for up to 12 weeks with results lasting up to 2 years.

B. Procedure: Approximately 20 cc of blood are drawn from the patient in the same way blood samples are taken for routine lab tests. The tubes of blood are put into a centrifuge, where the blood is spun in order to separate the red blood cells from the PRP. Once injected under the skin or applied topically onto the skin, the PRP releases growth factors and activates multi-potent stem cells to generate new, younger tissue. This new tissue synthesis includes new collagen for firmness and elasticity, new fatty tissue for plumpness and smoothness, and new blood vessels for a healthy rosy glow.

C. Discomfort & Risks: The injection and/or topical application of PRP is considered to be safe because cells from the patient’s own blood are used, which means there are no preservatives and no chance of the body rejecting the cells. The primary risks and discomforts are related to the blood draw where there is a slight pinch to insert the needle for collection and there is a potential for bruising at the site. Smokers have less positive response to this treatment than non-smokers, since the toxins in cigarette smoke block the response of the platelets. I understand that additional treatment side effects are generally temporary, related to PRP injections, and can include but are not limited to:

a. Needle Marks- Visible needle marks occur normally and resolve in a few days.
b. Swelling – An ice pack may be placed over the area until swelling subsides.
c. Itching - Temporary and generally intermittent.
d. Bruising – Bruising is always a possibility with any skin injection and may develop immediately or up to 24 hours following treatment. To reduce the risk of bruising, avoid aspirin, anti-inflammatory medications, and herbal supplements, including vitamins, for one week prior to and after your treatment. If you experience bruising, it will generally heal within 7-14 days and may be covered with makeup if desired.
e. Pain/Tenderness – May last up to 2 weeks. Tylenol may be taken to reduce discomfort if desired.
f. Lumps/Bumps – Will generally subside/diffuse within approximately 2 weeks after treatment.
g. Migration of PRP – PRP may migrate from its original injection site and produce fullness in adjacent areas.
h. Asymmetry - The human face is normally asymmetrical in its appearance and anatomy. There can be variation from one side of the face to the other in terms of the response to PRP and it may not be possible to achieve or maintain exact symmetry with PRP injections.
i. Infection – Infections are extremely rare but may require treatment including antibiotics if necessary.
j. Skin Necrosis- It is very unusual to experience death of skin and deeper soft tissues after injections.
k. Unsatisfactory Result – Some patients may have an unsatisfactory result that includes temporary visible irregularities, prolonged bruising, swelling, tenderness, and/or disappointment in the result.

D. Alternatives: PRP Therapy is strictly a voluntary cosmetic procedure; no treatment is necessary or required.  Alternative treatments may include, but are not limited to facial creams, Botox, dermal fillers, chemical peels, laser resurfacing, cosmetic surgery, or no treatment.

E. Clinical Photography: I understand that clinical photographs may be taken at each appointment and are considered a confidential and essential component of my medical record.  The photographs will not be used for or disclosed for any media purposes without my signed permission on a separate media consent form.

F. Results Not Guaranteed: I understand that although good results are expected, there cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek. I understand that PRP treatments will not cure any medical conditions nor provide immunity against re-occurrence of such conditions. The effects of PRP are temporary and vary per patient with some patients experiencing shorter or longer effects. The number of treatments needed vary per patient and may be affected by the following factors including but not limited to degree of skin irregularity; severity of volume loss; patient age; personal medical profile; basic metabolic rate; previous cosmetic procedures; history of trauma to the treated area; individual lifestyle choices; and individual patient preference. I understand and acknowledge that payment for the above procedure is non-refundable and that if more correction is desired I will be responsible for purchasing additional PRP procedures to achieve the outcome I desire.

G. Complete Medical History: I have truthfully and accurately disclosed all personal medical history information including but not limited to all previous aesthetic procedures; invasive medical procedures; my use of all medications, drugs, herbs, vitamins, or other supplements of any kind; and all known allergic reactions. I understand that failure to do so may negatively affect my treatment outcome. I further understand that elective aesthetic procedures should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that the providers Body and Soul are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said during each treatment should be construed as such. Because treatments should not be performed under certain medical conditions, I affirm that I have disclosed all my known medical conditions and all medications I am currently taking. I agree to keep Dr. Dustin Moffitt and Body and Soul updated as to any changes in my medical profile and understand that there shall be no liability on Dr. Dustin Moffitt and Body and Soul’ part should I fail to do so.

H. Topical & Oral Medications: I understand that prior to each treatment it is imperative that I report any topical or oral medications (prescription and non-prescription) that I am currently using or have used in the last 90 days. Should I begin using any new medications during the course of my treatments, I will inform my provider. I release Dr. Dustin Moffitt and Body and Soul of any and all responsibilities relating to adverse reactions due to non-disclosure.

I. Pre & Post Care Compliance: I acknowledge that Dr. Dustin Moffitt and Body and Soul has provided me with a copy of the “Pre and Post Care” instructions for this procedure. I understand it is important to follow these instructions to maximize treatment results and to minimize the chance of an adverse reaction. I accept all responsibilities of adverse reactions due to noncompliance with pre and post treatment care guidelines.

J. Questions & Concerns: I agree if I have any questions, prospective adverse reactions, or concerns regarding my treatment, I will contact Dr. Dustin Moffitt and Body and Soul within 2 weeks from the time of treatment to make arrangements to be evaluated. I understand that if I do not contact Dr. Dustin Moffitt and Body and Soul within 2 weeks from the time of treatment then Dr. Dustin Moffitt and Body and Soul may not be able to accurately determine whether my question or concern is directly related to the procedure. If I choose to consult my own physician or seek any other medical attention it is at my own expense.

K. Pregnancy (female patients only): Even though there is no evidence of complications, we will not perform this treatment if you are pregnant. I certify that I am not currently pregnant. I agree that if I become pregnant at any time during the course of my treatments I will inform Dr. Dustin Moffitt and Body and Soul.

L. Release of Liability: I release all Dr. Dustin Moffitt and Body and Soul staff from liability associated with this procedure except for any liability that may be imposed by the laws of the state of Kansas.

M. Binding Arbitration Agreement: In the case of any dispute, I agree to make a good faith effort to resolve the matter directly with Dr. Dustin Moffitt and Body and Soul. If the matter cannot be resolved directly with Dr. Dustin Moffitt and Body and Soul I agree to forego litigation and submit to binding arbitration in the state of Kansas.

N. Certification of Consent to Proceed with Treatment: I understand that this treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. I understand that if I am not willing to accept all risks associated with this procedure then I should not have PRP treatment. I certify that all my questions have been addressed and answered to my satisfaction, that I have read this entire consent, and that I understand and agree to the information herein. I understand that to receive PRP treatment with Dr. Dustin Moffitt at Body and Soul, I must comply with all stipulations outlined in this consent form; if I do not agree then I will not be able to proceed with treatment. I freely and voluntarily accept all risks associated with PRP and elect to proceed with treatment today as well as future and ongoing treatments.

Date Signed: November 16, 2019

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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.
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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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