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PRP (Platelet Rich Plasma) Consent

Platelet Rich Plasma (PRP) Consent

(Aesthetics)

Date:

Patient Information

Patient Name: {{patient_first_name}} {{patient_last_name}}
Date of Birth: {{patient_birthdate}}

Treatment Information

I understand that I will be receiving Platelet Rich Plasma (PRP) treatment, which involves drawing my blood, processing it to concentrate platelets, and re-injecting it to promote healing and rejuvenation.

Consent Statements

Please initial each statement:

Signatures

Patient Signature: _________________________ Date:

Provider Signature: Date:

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.

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Rita Brasler
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Rita Brasler

Party ID: 30e85bbc-7a7d-4b64-a846-70c53eececbe

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Timestamp

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January 11, 2026 2:19 am EDT

Document PRP (Platelet Rich Plasma) Consent
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