Introduction

This consent form provides essential information about Platelet-Rich Plasma (PRP) therapy for hair loss, detailing its potential advantages, risks, and limitations. The procedure involves drawing your blood, processing it to extract concentrated platelets, and injecting the platelet-rich plasma into your scalp to encourage hair growth. While many clients achieve favorable results, outcomes can differ from person to person.

Medical Information

1. Have you ever experienced severe allergic reactions, such as anaphylactic shock?

Yes

No

2. Do you have a history of keloid or hypertrophic scarring?

Yes

No

3. In the last 10 days, have you used Aspirin, Warfarin, other anticoagulants, or medications/supplements that might affect bleeding?

Yes

No

4. Do you have any medical conditions such as angina, epilepsy, hepatitis, or autoimmune diseases? If yes, please specify.

Yes

No

If Yes, specify

5. Are you currently pregnant or suspect you might be pregnant?

Yes

No

6. Are you breastfeeding?

Yes

No

By ticking the box, I confirm that, to the best of my knowledge, the medical history I have provided is accurate, and there are no additional health concerns I need to disclose.

Acknowledgment of Expectation

I acknowledge and understand that:

PRP therapy is designed to promote hair growth, but results are not guaranteed ,however, we expect good results.
The effectiveness of PRP therapy varies among individuals, and there is a possibility that you may not experience noticeable improvement depending on the stage of the hair loss, age, and medical state and sometimes lifestyle.

Potential Risks and Complications

I have been informed about the possible risks and side effects of PRP therapy, which include but are not limited to:

Pain or Discomfort: Mild to moderate pain at the injection site.
Swelling, Bruising, or Redness: Temporary swelling, bruising, or redness around the treated area.
Infection: Although uncommon, there is a potential risk of infection.
Dizziness or Fainting: Some individuals may feel lightheaded during or after the procedure.
No Improvement: There is a possibility that the treatment may not lead to any noticeable improvement.

Contraindications

I understand that PRP therapy is not suitable for individuals with certain conditions, including but not limited to:

Active cancer or a history of blood-related disorders.
HIV infection.
Thrombocytopenia (low platelet count).
Ongoing anticoagulant therapy.
Active infections or chronic skin conditions at the treatment site.
Conditions or treatments that suppress the immune system.

Liability Waiver

I understand and agree that:

Trinity Trichology Clinic cannot guarantee specific results from PRP therapy.
The clinic is not liable for any complications or dissatisfaction with the treatment outcomes.
Failing to disclose accurate medical information could compromise my safety during the procedure.

Consent to Treatment

I confirm that I have carefully read and understood this consent form. I have had the opportunity to ask questions regarding PRP therapy, including its risks, benefits, and alternatives.

By ticking below, I voluntarily consent to undergo PRP therapy for hair loss.

Tick here to consent