PRF Consent Form

Consent PRF

PLATELET RICH FIBRIN (PRF) CONSENT FORM

This document is intended to serve as confirmation of informed consent for PRF as ordered by Michele Lane, DNP, APRN, CNP-F, L3 Aesthetics.

INSTRUCTIONS

This is an informed consent document that has been prepared to help inform you about the Platelet Rich Fibrin (PRF) technique. It is important that you read this information carefully and completely. Please sign the consent indicating that you have read and understand this consent form and the procedure proposed by your provider.

INTRODUCTION

The Platelet-Rich Fibrin (PRF) technique uses the latest generation of Blood Concentrates to generate a complex Fibrin Matrix rich in Platelets, Leukocytes and Mesenchymal stem cells. This process helps constantly release growth factors and interleukins for up to 10 days which accelerate tissue healing and the regeneration processes. PRF is effective in most cases; no guarantees can be made that a specific patient will benefit from this procedure. Additionally, the nature of cosmetic procedure may require a patient to return for numerous visits in order to achieve the desired results or to determine whether PRF may not be completely effective at treating the particular condition. The healing process takes time and the final result won’t be readily visible for many months.

INDICATIONS OF USE

PRF is used to accelerate tissue healing, hair restoration, and skin regeneration through the use of Blood Concentrate.

POSSIBLE RISKS AND SIDE EFFECTS ASSOCIATED WITH PRF

1. DISCOMFORT: Discomfort may be experienced during blood draw where there is a slight pinch to insert the needle for the blood collection as well as during the procedure if PRF is injected into the site. Repeat injections may be necessary. 2. BRUISING, SWELLING, INFECTION: With any minimally invasive procedure, bruising of the treated area may occur. Additionally, there may be swelling noted. Finally, skin infection is rare, but always a possibility with any injection into the skin. 3. SCARRING: Scar at entry point is extremely rare but must always be considered a possibility when entering the skin. Delayed wound healing and/or scarring may occur. 4. CONTRAINDICATIONS: Smokers may have less response to this treatment as toxins in smoke block the response of the Stem Cells. Cell death or Fibrosis may occur.

TREATMENT

You may take pain medication such as Tylenol. A numbing cream is applied to the area of treatment. Approximately 10-40ml of whole blood is drawn from your arm. The tubes of blood are centrifuged to separate the component cells. Platelets, Leukocytes and Mesenchymal stem cells are separated and used for this procedure. The liquid is then transferred into a syringe and injected using a tiny needle.

• FINANCIAL RESPONSIBILTIES:

The cost of procedure may involve several charges for the services provided which will be discussed and agreed upon prior to procedure. I realize that I am financially responsible for all services provided.

ADDITIONAL PROCEDURES MAY BE NECESSARY

In some situations, it may not be possible to achieve optimal results with a single procedure and other procedures may be necessary. Although good results are expected, there cannot be any guarantee or warranty expressed or implied on the results that may be obtained. There may be some variation in achieving the results requested as everyone’s body type is different and may have a different response. I understand that the results may relax over time and additional procedures may be required. As in all medical treatment, complications or delay in recovery may occur which could lead to the need for additional treatment, and could also result in economic loss to me because of my inability to return to activity as soon as anticipated.

CONSENT

Your consent and authorization for this procedure is strictly voluntary. By signing this informed consent form, you hereby grant authority to your provider to use PRF for regeneration purposes and/or to administer any related treatment as may be deemed necessary or advisable in the treatment of your condition. The nature and purpose of this procedure and the potential complications and side effects have been fully explained to me. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions. I understand that No refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me by my provider and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office. I hereby give my voluntary consent to this procedure and release my provider, the facility, 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 is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. Should I have any questions or concerns regarding my treatment / results, I will notify this office immediately so that timely follow-up and intervention can be provided.

You have the option to sign this Agreement electronically or sign a paper copy of this Agreement. By signing electronically using any device, means, or action, you consent to this Agreement's legally binding terms and conditions. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Michele Lane. You are also confirming that you are authorized to enter into this Agreement on your behalf.

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