Micro-needling with Platelet Riche Plasma (PRP)Consent Form I authorize Sara Aesthetics to perform micro-needling treatment with platelet rich plasma
(PRP). I understand that this procedure is elective.
Micro-needling treatment with PRP is not recommended for those who:
• Are pregnant or breast feeding
• Active Skin Caner
• Have herpes, active cold sores, psoriasis, warts, raised moles, sun burn, or active skin infection the day of treatment
• Have been taking Accutane
• Have had laser, waxing, or a chemical peel in the last week
• Chemotherapy
• Severe metabolic and systemic disorders
• Abnormal platelet function (blood disorders, i.e., Haemodynamic Instability,
Hypofibrinogenemia, Critical Thrombocytopenia)
• Chronic Liver Pathology
• Anti-coagulation therapy
• Underlying Sepsis
• Systemic use of corticosteroids within two weeks of the procedure
What to expect:
•Depending on the area of your face or body being treated, the procedure is well tolerated and, in some cases, virtually painless, feeling only a mild prickling sensation.
•A topical anaesthetic will be applied to your skin prior to treatment to reduce or eliminate pain or discomfort.
•Your skin will be pink or red after treatment, much like a sun burn for 24-72 hours following.
•Minor bleeding and bruising are possible depending on the number of times it is pressed across an area.
•Approximately 15cc of blood are drawn from the patient in the same way blood samples are taken for lab tests to obtain the PRP.
•Tubes of blood are placed in centrifuge where it is spun to separate the red blood cells from the PRP. The PRP is either injected or applied topically onto the skin.
•Your skin may feel warm, tight, and itchy for the first hours after treatment.
•Do not wash treated area for 24 hours.
•Read and follow the post-‐treatment instructions.
Possible side-‐effects:
Side effects are minimal with this type of treatment and typically include:
• minor flaking or dryness of the skin with scab formation in rare cases.
• Milia (small white bumps) may form; these can be removed by the practitioner.
• Hyper- pigmentation can occur very rarely and usually resolves after a month.
• Temporary redness and mild-‐sunburn effects may last up to 4 days.
• Freckles may temporarily lighten or permanently disappear in treated areas.
• Crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the desired result.
The benefits and risks of the procedure have been explained to me and I accept these benefits and risks.