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

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