This form is used to inform patients of potential risks and indications for a Plasma-Rich-Platelet (PRP) Injection. Please read through this form in its entirety before signing at the bottom. If you have any questions or concerns about this form, please ask a Pure Cosmetic staff member before signing.

About PRP

Platelet Rich Plasma, also known as "PRP" is an injection treatment whereby a person’s own blood is used. A fraction of blood (20cc) is drawn up from the individual patient into a syringe. This is a relatively small amount compared to blood donation which can remove 500cc. The blood is spun in a special centrifuge to separate its components ( Red Blood Cells, Platelet Rich Plasma, Platelet Poor Plasma and Buffy Coat).The Platelet Rich Plasma and Buffy Coat is first separated and combined then activated with a small amount of calcium gluconate which acts as an activation agent and scaffold to keep the PRP where the injector intends to treat. Platelets are very small cells in your blood that are involved in the clotting and healing process. When PRP is injected into the damaged area it causes a mild inflammation that triggers the healing cascade. As the platelets organize in the treatment area they release a number of enzymes to promote healing and tissue responses including attracting stem cells and growth factors to repair the damaged area. As a result new collagen begins to develop. As the collagen matures, it begins to shrink causing the tightening and strengthening of the damaged area. When treating injured or sun and time damaged tissue, they can induce a remodeling of the tissue to a healthier and younger state. The full procedure takes approximately 45 minutes to an hour. Generally 2-3 treatments are advised,however, more may be necessary for some individuals. Touch up treatments may be done once a year after the initial group of treatments to boost and maintain the results.'

Safety Information

PRP'S SAFETY has been established for over 20 years for its wound healing properties and it's proven effectiveness has extended across multiple medical specialties including cardiovascular surgery, orthopedics, sports medicine, podiatry, ENT, neurosurgery, dental and maxillofacial surgery (dental implants and sinus elevations), urology, dermatology (chronic wound healing), and ophthalmology, cosmetic surgery. PRP's emergence into aesthetics and skin rejuvenation began i n 2004 in Europe, Asia, Australia, and South America in countries such as The United Kingdom, Japan, Spain, Portugal, Switzerland and Argentina to name a few. Areas typically treated for aesthetic purposes and skin rejuvenation include: Crinkling skin around the eyes, cheeks and mid­ face, neck, jaw-line, chest and décolletage, back of hands and arms, lips, and to stimulate hair growth on scalp. Almost all skin tones show that PRP is safe and effective because your own enriched plasma is used.


Along with the benefit of using your own tissue therefore virtually eliminating allergies, there is the added intrigue of mobilizing your own stem cells for your benefit. PRP has been shown to have overall rejuvenating effects on the skin including: improving skin texture, thickness, fine lines and wrinkles, increasing volume via the increased production of collagen and Elastin, and by diminishing and improving the appearance of scars. The most dramatic results to date have been the "crepy" skin problems in areas such as under the eyes, neck, and décolletage. It is not designed to replace cosmetic surgery as there are some cases where those procedures would be more appropriate.Other benefits include: minimal down time, safe with minimal risk, short recovery time, natural looking results; no general anesthesia is required.

I have read over the safety information and potential benefits of PRP Injection Treatments.


PRP used for aesthetic procedures is safe for most individuals between the ages of 18-80. Parental Consent required for patients under 18. There are very few contraindications, however, patients with the following conditions are not candidates:

  • Acute and Chronic Infections
  • Skin diseases (i.e. SLE, porphyria, allergies)
  • Cancer
  • Chemotherapy treatments
  • Severe metabolic and systemic disorders
  • Abnormal platelet function (blood disorders, i.e. Haemodynamic Instability, Hypofibrinogenemia, Critical Thrombocytopenia)
  • Chronic Liver Pathology
  • Anti-coagulation therapy,
  • UnderlyingSepsis and
  • Systemic use of corticosteroids within two weeks of the procedure.

Risks and Complications

Some of the Potential Side Effects of Platelet Rich Plasma include:

  • Pain at the injection site
  • Bleeding, Bruising and/or Infection as with any type of injection
  • Short lasting pinkness/redness (flushing) of the skin
  • Allergic reaction to the solution
  • Injury to a nerve and/or muscle as with any type of injection
  • Itching at the injection site(s);
  • Nausea /vomiting

The following are possible with any simple injection and not specific to PRP Therapy:

  • Dizziness or fainting
  • Temporary blood sugar increase
  • Swelling
  • Minimal effect from the treatment.

I understand there are potential risks and complications to the PRP Injection treatments, and have disclosed any and all contraindications for treatment. If my medical history changes, I understand that I must notify Pure Cosmetics in writing immediately.


  1. Do Nothing
  2. Surgical intervention may be a possibility
  3. Injections with neurotoxins
  4. Injections of dermal filling agents
  5. Laser & light based treatments like Pulsed Light
  6. Chemical peels


  • Results are generally visible at 4 weeks and continue to improve gradually over ensuing months (3-6) with improvement in texture and tone. Advanced wrinkling cannot be reversed and only a minimal improvement is predictable in persons with drug, alcohol, and tobacco usage.
  • Severe scarring may not respond. Current data shows results may last 18·24 months.

I understands that indivuals are different so there will be variations of results from one person to another.


My consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, I hereby grant authority to the medical provider to perform Platelet Rich Plasma (PRP) injections to area(s) discussed during our consultation, for the purpose of aesthetic enhancement and skin rejuvenation. I have read this informed consent and certify I understand its contents in full.

All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them.

I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment. I also understand this procedure is "elective" and not covered by insurance and that payment is my responsibility. Any expenses which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.

I hereby give my voluntary consent to this PRP procedure and release the practice, its medical staff, and technicians from liability associated with the procedure. I certify that l am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. I agree that if I should have any questions or concerns regarding my treatment I results I will notify this office at 866-691-4427 and/or the provider immediately so that timely follow-up and intervention can be provided.

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