PRP (Platelet-Rich Plasma) – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently receiving medical treatment or taking medications? *

Yes

No

If yes, please specify: *

Are you taking blood thinners, steroids, or immunosuppressive drugs? *

Yes

No

Have you had recent cosmetic procedures (fillers, Botox, peels, laser)? *

Yes

No

If yes, please describe and provide dates: *

Treatment Goals and Preferences

Have you had PRP treatments before? *

Yes

No

Let us know the date and your experience : *

Do you use any active skincare ingredients (acids, retinoids, vitamin C)? *

Yes

No

Do you wear SPF everyday? *

Yes

No

Procedure Information and Expectations

PRP (Platelet-Rich Plasma) is derived from your own blood and reinjected into the skin or scalp to promote healing and rejuvenation.

A small amount of blood is drawn and spun in a centrifuge to isolate growth factor-rich plasma.

Topical anesthetic may be applied to reduce discomfort during microinjection or microneedling.

A series of treatments is often recommended for optimal results.

Risks, Side Effects, and Acknowledgements

Please read and initial each statement for PRP Treatment: *

I understand that PRP is a natural procedure using my own plasma for healing and rejuvenation.

I acknowledge that potential side effects include swelling, bruising, redness, tenderness, or infection.

I understand that results may take several weeks and vary from person to person.

I understand that no guarantees are offered regarding outcome or duration of effect.

I will avoid anti-inflammatory medications, alcohol, and exercise 24–48 hours post-treatment.

I confirm that I have disclosed all relevant medical history and current medications.

I agree to clinical photos being taken for documentation (not for public use without consent).

Client Declaration and Consent

Check boxes for PRP Treatment : *

I confirm that the information I have provided is accurate and complete.

I understand the PRP procedure, its benefits, risks, and post-treatment care.

I have had the opportunity to ask questions and all were answered to my satisfaction.

I voluntarily consent to undergo PRP treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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PRP (Platelet-Rich Plasma) – Comprehensive Consent and Concern Form

Treatment Goals and Preferences

Procedure Information and Expectations

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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