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Injections and Related MedSpa Consent Form 


Platelet Rich Plasma, known as PRP, is derived from the patient’s own blood. A fraction of blood is drawn from the patient into a syringe, it is spun in a special centrifuge to separate its component (red blood cells, platelet rich plasma, white blood cells & platelet poor plasma). The plasma is collected, and solutions are added and then injected. This procedure takes 15-45 minutes, and 2-3 treatments are advised.


Preparation: Avoid the following medications and herbs that may increase bleeding and bruising for at least 2 weeks. -Any NSAID’s (ibuprofen, Aleve, Motrin, Advil, or Aspirin) -Coumadin -Garlic -Ginseng -Gingko Biloba -Glucosamine


1-Minimal down time.

2-Safe and minimal risk.

3-Regenerates tissues.

4-Short recovery time.

Contraindications: Patients with the following conditions are not candidates:

1-Pregnancy Lactation

2-Acute & Chronic Infections

3-Skin Diseases (SLE, Porphyria & Allergies)


5-Chemotherapy Treatments

6-Severe Metabolic & Systemic Disorders

7-Abnormal Platelet (blood disorders, 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 2 weeks of procedure


My consent and authorization for this elective procedure are strictly voluntary. By signing this informed consent form, I hereby grant authority to the physician/ practitioner to perform Platelet Rich Plasma Injections to the area(s) discussed during our consultation. For the sole purpose of rejuvenation and regeneration of affected tissue. I have read this informed consent and certify I understand its contents 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.


I acknowledge that the following is a risk of Vaginal PRP:

-No effect at all

-Injection site infection/ Hematoma

-Hematuria (blood in urine)

-Hypersexuality (overactive sex drive)

-Increased sexual arousal

-Increased vaginal lubrication

-Decreased sensitivity

-Urinary continence


I acknowledge that the following is a risk of Scalp PRP:

-No effect at all

-Worsening Hair Loss 

-Severe headache

-Injection site infection/ Hematoma

-Swelling that may extend into the tissue around the eyes (may last several days)


I acknowledge that the following is a risk of Facial PRP:

-Injection site infection/ Hematoma


-Swelling and discoloration

-Swelling and redness lasting up to 72 hours is possible


I acknowledge that the following is a risk of Joint PRP:

-Injection site infection/ Hematoma

-Nerve damage

-Joint space infection & destruction

-Worsening of pain

-Temporary weakness and numbness

Thanks for submitting!

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