PRP/PRF Hair & Scalp Consent Form

A copy of this completed consent form along with post treatment advice will be emailed to the email address you provide below.

    Treatment Goals Medical History Lifestyle Factors
    Acknowledgement and Consent
    By signing this form, I confirm that:
    • I have provided accurate and complete health information to the best of my knowledge.
    • I understand that results will vary between individuals due to the natural variation in the quality of Platelet-Rich Plasma (PRP) or Platelet-Rich Fibrin (PRF).
    • I understand that although I may notice a change after my first treatment, I may require a series of up to six sessions to achieve my desired outcome.
    • The procedure, its potential side effects, and alternative methods have been explained to me, including their respective advantages and disadvantages.
    • I understand that while good results are expected, complications are possible, and their nature cannot be fully anticipated. Therefore, no guarantees, expressed or implied, have been made regarding the success or outcome of the treatment.
    • I am aware that the effects of PRP treatment are not permanent, as natural degradation will occur over time.
    • I authorise Qaya Clinic to perform the injection of PRP (Platelet-Rich Plasma) or Platelet-Rich Fibrin (PRF) for hair rejuvenation purposes by needles, mesotherapy gun or with a microneedling device.
    • I understand that this consent form is valid for up to six applications of PRP/PRF treatment. After this, I may be required to complete a new consent form.
    • I have read (or have had read to me) and understand this consent form.