PRP (Platelet Rich Plasma) Consent


Platelet Rich Plasma (PRP) 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:

1. I understand the nature of PRP treatment.

2. I understand the potential risks and benefits.

3. I have been informed of alternative treatments.

4. I understand that results are not guaranteed.

5. I will follow all post-treatment instructions.

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.

Form Complete

Leave this empty:

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Edvin Habibovic
(Awaiting Signature)

Edvin Habibovic
(Awaiting Signature)

Edvin Habibovic
(Awaiting Signature)

Russil Almeshhedani
(Awaiting Signature)

Matt Williams
(Awaiting Signature)

Luis Escobar
(Awaiting Signature)

Ava Peters
(Awaiting Signature)

Deana Carl
(Awaiting Signature)

Chelsey Mcpheeters
(Awaiting Signature)

Justin Newton
(Awaiting Signature)

Justin Newton
(Awaiting Signature)

Macauley Murphy
(Awaiting Signature)

Macauley Murphy
(Awaiting Signature)

Raya Habeeb
(Awaiting Signature)

Veronica Mancilla Garcia
(Awaiting Signature)

Veronica Mancilla Garcia
(Awaiting Signature)

Veronica Mancilla Garcia
(Awaiting Signature)

Veronica Mancilla Garcia
(Awaiting Signature)


Signature Certificate
Document name: PRP (Platelet Rich Plasma) Consent
lock iconUnique Document ID: deeec35ff5e490c1127c49b6d82cb39638cffdae
Edvin Habibovic
Party ID: 682ddac6-6b88-4fef-9b5e-3c8ac653b575
Awaiting signature
Russil Almeshhedani
Party ID: f7a34b72-e542-43f9-bb63-0fb5b3a6cd67
Awaiting signature
Matt Williams
Party ID: 6019ef63-f326-4adc-b831-8634c8cdb386
Awaiting signature
Luis Escobar
Party ID: 635e739d-8c7a-4179-b032-76b23dfd6f89
Awaiting signature
Ava Peters
Party ID: 1ff37cfd-4118-4aed-8fb8-569baeee74f8
Awaiting signature
Deana Carl
Party ID: dda0d286-da38-4e73-9d17-1b8bf4c70fae
Awaiting signature
Chelsey Mcpheeters
Party ID: 9c237f39-cf0a-48ee-a38f-7362b38935c7
Awaiting signature
Justin Newton
Party ID: 5b240894-bcfc-4551-b051-52d4efe4e7cf
Awaiting signature
Macauley Murphy
Party ID: 0549b773-bb96-42ad-a1e3-f78e9a71a2fc
Awaiting signature
Raya Habeeb
Party ID: 0831e2b4-c638-49cc-ab36-9cce4617a460
Awaiting signature
Veronica Mancilla Garcia
Party ID: abfa3f7f-eb37-48f2-9446-3a8a48d33c08
Awaiting signature
Timestamp Audit
December 13, 2025 1:56 pm EDTPRP (Platelet Rich Plasma) Consent Uploaded by ENNU Patient Docs - admin@ennulife.com IP 24.238.5.27
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