PRP TREATMENT CONSENT FORM

Full Name:

Have you received injections of Poly-L-Lactic Acid (Sculptra), Polyacrylamide (Aquamid), or any other injectable outside Australia within the last three (3) years?

Yes
No

Practice Name (if applicable):

GP Name:

GENERAL HEALTH QUESTIONNAIRE

It is crucial to provide accurate answers to the following questions. If unsure, consult with your physician before proceeding.

Please tick all that apply:

Blood disorders or clotting abnormalities

Active skin infection at the treatment site

Autoimmune disease

Recent viral or bacterial infection

Pregnancy or breastfeeding

Allergies to Anaesthetics or Medications

Other medical conditions or concerns

Previous cosmetic or medical procedures (if any):

Procedure:

CLIENT ACKNOWLEDGEMENT & CONSENT

By signing below, I acknowledge and agree to the following:

Nature of Treatment

  • I have discussed the nature of my condition and the proposed procedure (PRP) with my physician, including the rationale for treatment, alternative methods, and their respective advantages and disadvantages.

Potential Risks and Outcomes

  • I have been informed that possible risks and complications include, but are not limited to:
    • Minimal results
    • Infection
    • Swelling, redness, or tenderness
    • Bruising or bleeding at the injection site
    • Temporary discoloration
    • Allergic reactions
    • Scarring or fibrosis at the injection site
  • I understand that the results are not permanent as collagen degradation will naturally occur over time.

Personalised Risks

  • Additional risks specific to my medical condition or treatment circumstances have been explained (if any):

Limitations and Guarantees

  • While good results are expected, I understand there are no guarantees regarding the success of the treatment or the outcomes achieved.

Opportunity for Questions

  • I have had the opportunity to ask questions, and my concerns have been addressed to my satisfaction.

General Practitioner Consultation

  • I have been informed that I may seek advice from my GP before proceeding with this procedure.

Completion of Form

  • I confirm that all details have been completed prior to signing, including risks, treatment details, and any named physician or assistant.

Consent for Information Use

  • I understand the information collected in this form is necessary to ensure the procedure is conducted appropriately and safely.
CONSENT

I hereby authorise Dr. Maria Mackey and/or her associates or assistants of her choice to perform PRP therapy on me.

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Please click on the Tick icon() to verify your signature. After that you can submit the form.