PRP (Platelet‐Rich Plasma) Therapy Consent Form
Informed Consent for PRP (Platelet‐Rich Plasma) Therapy
Aloha thank you for entrusting your health with our clinic. At this time, you have a pain problem that has not been relieved by routine treatments. Benefits include increased likelihood of correct diagnosis and /or of decrease or elimination of pain. Platelet‐rich plasma is a fraction of your blood which contains a high concentration of platelets. These are known to contain large quantities of growth factors which attract stem cells and stimulate the healing of damaged tissues. Clinical work over the last several years has established the safety and usefulness of platelet‐rich plasma (PRP) for tissue repair and healing in joints resulting in reduced pain and improved function for many who have had this procedure. Platelet Rich Plasma is an established treatment technique used to tighten and strengthen weak and damaged ligaments and tendons which are believed to cause pain and instability. It is also used to decrease pain and improved function. The technique requires the injection of Platelet Rich Plasma derived from your own blood. The sight of the injection is where the ligament or tendon attaches to the bone, at the joint capsule or inside the joint. An extensive discussion was conducted of the natural history of the disease and the variety of surgical and non-surgical treatment options available to the patient. A risk/benefit analysis was discussed with the patients reviewing the advantages and disadvantages of intervention at this time. A full explanation was given of the nature and the purpose of the procedures and anesthesia, its benefits, possible alternative methods of treatment, the risks involved, the possibility of complications, the foreseeable consequences of the procedures and the possible results of non-treatment.
Patient will be injected with PRP to the following area(s):
Right Left Bilateral (Both)
Your medical provider believes the benefits of the procedure outweigh its risks or it would not have been offered to you, and it is your decision and right to accept or decline to have the procedure done.
BENEFITS of PRP: PRP is autologous (using your own blood) therefore eliminating allergy potential. PRP has been shown to have tissue regenerating effects. Other benefits include minimal down time, safe with minimal risk, short recovery time, and no general anesthesia is required.CONTRAINDICATIONS: PRP use is safe for most individuals between the ages of 18- 80. There are very few contraindications, however, patients with the following conditions are not candidates: 1. Pregnancy or Lactation 2. Acute and Chronic Infections 3. Skin diseases (i.e. SLE, porphyria, allergies) 4. Cancer 5. Chemotherapy treatments 6. Severe metabolic and systemic disorders 7. Abnormal platelet function (blood disorders, i.e. Hemodynamic Instability, Hypofibrinogenemia, Critical Thrombocytopenia) 8. Chronic Liver Disease 9. Anti-coagulation therapy (Coumadin, Warfarin, Plavix, Aspirin, Lovenox) 10. Underlying Sepsis 11. Systemic use of corticosteroids within two weeks of procedureGENERAL CONSENT: 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 (aka PRP) injections to the 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 content in full. All 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 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. PLATELET RICH PLASMA (PRP) INJECTION Information and Informed Consent I hereby give my voluntary consent to this PRP procedure and release Blessed Hands Clinic Inc, its medical staff, and specific technicians from liability associated with the procedure. I certify that I 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 spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I agree that if I should have any questions or concerns regarding my treatment results, I will notify Blessed Hands Clinic Inc. and/or the provider immediately so that timely follow-up and intervention can be provided. CONSENT FOR ANESTHESIA When local anesthesia and/or sedation is used by the provider: I consent to the administration of such local anesthetics as may be considered necessary by Blessed Hands Clinic inc. staff in charge of my care. I understand that the risks of local anesthesia include local discomfort, swelling, bruising, allergic reactions to medications, and seizures from lidocaine.ALTERNATIVES: to PRP: Alternatives to PRP elective procedures are: 1. Do Nothing 2. Surgical intervention may be a possibility 3. Administration of approved medications 4. Physical Therapy 5. Laser or other ablative technology
PHYSICIAN ATTESTATION: I have explained the procedure(s), alternative(s), and risks to the person or persons whose signatureis affixed above. The patient has verbally communicated to me that they understand the contents of this form. PhysicianDeclaration: I and/or my associate have explained the procedure and the pertinent contents of this document to the patient andhave answered all the patient’s questions. To the best of my knowledge, the patient has been adequately informed, and the patienthas consented to the above-described procedure.
_________________________ X ______________________________ ____________Medical Provider Name Signature Date
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Document Name: PRP (Platelet‐Rich Plasma) Therapy Consent Form
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