Client Information and Consent for Aesthetic Applications and Skin Rejuvenation Platelet Rich Plasma (PRP)/My Cells (U.S.A.) Treatments

Description of PRP Procedures

Client name: File No. :

I hereby authorize AL DIMASHQI MEDICAL CENTER (DMC) to perform PRP on me. I understand that this technique requires the injection of PRP to stimulate new collagen production, and to re-energize cells into rejuvenating themselves.

Results are generally visible at 3 weeks and continue to improve gradually over the next 3-6 months with improvement in texture and tone. Current data shows results may last 18-24 months. Of course all individuals are different so there will be variations from one person to the next.

Pre and Post Treatment Instructions:

I understand that compliance with Pre and Post treatment guidelines, presented, discussed and handed to me are crucial for success of PRP treatment and for minimizing any undesirable side effects and complications.

Contraindications

PRP used for aesthetic procedures is safe for most individuals between the ages of 25‐80. There are very few contraindications, however, you should not have PRP treatment done if you have any of the following conditions:

1) Acute and Chronic Infections, 2) Skin diseases (i.e. SLE, porphyria, allergies), 3) Facial cancer, 4) Chemotherapy, 5) Severe metabolic and systemic disorders, 6) Blood disorders and platelet abnormalities, 7) Chronic Liver Pathology, 8) Anti‐coagulation therapy (i.e.: Warfarin, Aspirin, Garlic, Vitamin E etc..), 9) Anti-inflammatory therapy (ie : Neurofen, Voltaren, Diclofenac, or Naproxen etc..), 10) Underlying Sepsis, 11) Systemic use of corticosteroids within two weeks of the procedure, and 12) pregnant or breastfeeding.

Adverse experiences or side effects

- Some discomfort may be experienced during and after treatment. This discomfort is typically minimal but if the treated area is very uncomfortable, oral pain reliever; such as Extra Strength Tylenol or Panadol Extra.

- Mild to moderate swelling of the treated area, which initially increases and can last for about 12- 24Hours.

- Allergy to any of the substances utilized during the procedure, such as the anesthetic, antiseptic, or dressing. This is usually minor and self-limiting.

- Tingling sensation while the cells are being activated.

- In rare cases skin infection may occur, which is easily treated with an anti-biotic. Most infections will present after the 48 hour mark with red, warm, injection site, and worsening pain.

- It is very IMPORTANT to follow up all post-treatment guidelines carefully to minimize these chances. If signs of infection develop, I have to call DMC at +971 6 556 3553.

ACKNOWLEDGMENT

- 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.

- By my signature below, I acknowledge that I have read (or it has been read to me) and fully understand the contents of this informed consent, and that I have had all my questions answered to my satisfaction by DMC licensed doctor. I hereby give my voluntary consent to the physician to perform PRP injections on me, for the purpose of aesthetic enhancement and skin rejuvenation. And I release AlDIMASHQI MEDICAL CENTRE and its staff from all liability associated with this procedure. Furthermore, my signature below indicates my agreement to adhere to all safety precautions and regulations during the treatment.

- I understand that Payment in full for treatment is required at the time of service and is non‐refundable.

- I have been informed that Photographic documentation of treated area will be taken should I ask for that.

This consent form is valid for all future PRP treatments performed at DMC on me.

For women of childbearing age: confirm that I am not pregnant or nursing.

Patient Name

Patient Signature

Date/Time