consent form prp mesotherapy peeling english

File Number:

Consent Form - PRP + Mesotherapy + Peeling

Terms and Conditions:

• Side effects of PRP: Minor discomfort (pin prick senation) from blood draw, Dizziness and feeling faint (rare), A temporary headache, Redness in the scalp for 2-4 days, Swelling in the forehead and around the eyes. There may rarely be swelling discoloration and bruising associated with the procedure. Reaction to local freezing medications 3, Hair loss (temporary) in the existing hair. This is often termed ‘shock loss.’ Infection (very rare), Itching at the injection sites, Minor bleeding and bruising at the sites of injections, Injury to nerve during blood draw (very rare.

• I understand that hair loss is sometimes continuous throughout life for some people. I understand that additional PRP injection procedures may be needed and that some individuals would expect 1-3 sessions per year.

• I declare I do not have any of the following conditions which might otherwise not make me a candidate: Current infections Skin diseases such as lupus or porphyria Current cancer Current chemotherapy treatments Severe metabolic or systemic disorders Liver disease Abnormal platelet function (blood disorders) Anticoagulation therapy Current use of corticosteroids Steroid injections in my scalp in the last month

• I understand that there are some risks with any procedure. The following is a list of potential risks with Mesotherapy: Bruising of the skin, Swelling, redness, or nodules are possible depending on location treated, Nausea, dizziness, and possible allergic reaction to the Hyaluronidase may occur,Skin infection is a possibility with any injection type procedure,

• I acknowledge that I have been informed about the medications that will be used in my treatment and give consent to their use in my treatment. I know that Mesotherapy is not an exact science

• I understand that anytime after a peel treatment the skin barrier is compromised, there is a small risk of infection. I will contact the therapist immediately should this happen.

• I understand that following the treatment my skin may appear red and feel like it has slight sunburn.

• Possible side effects after a peel treatment include and are not limited to: slight or extreme redness, swelling, stinging, itchy, tenderness, dry or flaking skin. I understand that i am not to pick the flaking skin as this could cause unwanted pigmentation. Most side effects will gradually diminish over time as healing may take several days or longer.

• Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

• Client experiences may vary.

• Any contraindications will void this treatment

• This treatment cannot be transferred to another person

• Once the injection has been given, refunds are prohibited

• Appointments preferences are based on availability

• I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me

• I have had sufficient time to consider the Cellfina® treatment and had the opportunity to ask questions, and all of my questions have been answered to my satisfaction and understanding

• Must notify the clinician if my medical history changes prior to subsequent treatments

• I consent to clinical photographs being taken of my treated areas for my personal health record only

• My signature below constitutes my acknowledgment and understanding of all this information

Patient Name

Patient Signature

Date & Time

Parent or Guardian (if patient is minor)

Witness