PRP/PRF Treatment Consent Form

About PRP/PRF: This treatment uses your own blood, which is processed to concentrate platelets and growth factors. These are then re-injected or applied to stimulate healing and rejuvenation. As it uses your own blood, allergic reactions are extremely rare.

Patient Information

Full Name

Date of Birth

Phone Number

Email Address

Treatment Type

Treatment Purpose (tick all that apply):

Facial Rejuvenation (Vampire Facial)

Hair Restoration

Under-eye Treatment

Acne Scarring

Combined with Microneedling

Other: _______________________

PRP/PRF System Used

Volume of Blood Drawn (ml)

Contraindications - Please confirm you do NOT have any of the following:

Pregnancy or breastfeeding

Blood disorders (e.g., thrombocytopenia, anaemia)

Blood-thinning medications (aspirin, warfarin, etc.) - discuss with practitioner

Active infection or illness

Cancer or history of blood cancers

Hepatitis or HIV

Chronic liver disease

Use of NSAIDs (ibuprofen, etc.) in past 48 hours

Autoimmune conditions

Skin infection in treatment area

Blood Draw Consent

Risks and Potential Complications

I understand that the following may occur:

At blood draw site: Bruising, soreness, rarely infection

At treatment site: Redness, swelling, bruising (may last several days)

Common: Tenderness and sensitivity

Uncommon: Lumps or nodules at injection sites

Rare: Infection

Rare: Nerve injury

Rare: Tissue damage

For hair: Results vary; not effective for all types of hair loss

Patient Acknowledgements

I have read and understood this consent form and agree to proceed with treatment.

Patient Signature

Date

Practitioner Signature

Practitioner Name (Print)