PRP INJECTION CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

PRE-INSTRUCTIONS

Patients with blood diseases are contradicted to undergo PRP injection. Patients must stop the following 3 days prior to the procedure:
Aspirin, brufen, sabofen, multivitamins, vit. e & green tea

SIDE EFFECTS:
• Pain or burning sensation
• Minimal swelling for 1 to 2 days
• Possible bruise for 2 to 14 days
• Redness
• Possible peeling and pigmentations
• Diabetic patient may experience delayed wound healing on the punctured sites
• Risk for infections due to multiple punctured sites so fucidin and bactroban ointment or cream must be applied 3x a day for 5 to 10 days post PRP injection.
• There is no risk of allergic reaction but may develop allergy due to local anesthesia. Visible result will not be immediate

POST INSTRUCTION:
You can apply makeup once the wound had healed usually 5 to 10 days. If you want to apply earlier, make sure to use new sponges or brushes.

I certified that I have read and understand the contents of this form and do realize the side effects and limitations involved. I hereby authorized my doctor to perform PRP injection and relieve my Doctor of the responsibility of any complications.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

"I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies ".

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :