PRP/PRF Pain Relief Consent Form

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

    Medical History Do you have any of the following medical conditions? Are you currently taking any of the following?
    Acknowledgement and Consent
    By signing this form, I confirm that:
    • I understand that PRP/PRF therapy involves the use of my blood to prepare platelet-rich plasma/fibrin for pain relief and healing purposes.
    • I acknowledge that results vary, and multiple sessions may be required to achieve optimal outcomes.
    • I have disclosed all relevant medical history, and I consent to the treatment based on this information. I have provided accurate and complete health information to the best of my knowledge.
    • I understand the potential side effects, including redness, swelling, bruising, or temporary discomfort.
    • 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 with at least two-six weeks between procedures, to achieve the maximum result.
    • 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 understand the treatment uses a needling medical device such as a microneedling device that creates controlled micro-medical needle punctures of the skin surface, or the use of needles or a mesotherapy gun may be used.
    • I am aware that the effects of PRP/PRF treatment are not permanent, as natural degradation may occur over time.
    • I authorise Qaya Clinic to perform the injection of PRP/PRF for pain relief and healing purposes
    • 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. If there are any changes to the information provided by myself in this consent form I will notify the practitioner prior to my next treatment.
    • I have read (or have had read to me) and understand this consent form.