Client Name: *

Date of Birth: *

Procedure Date: *

Introduction to PRP Hair Loss Treatment

Platelet-Rich Plasma (PRP) therapy for hair loss involves using your own blood to stimulate the growth of new hair. A small sample of your blood is drawn, processed to concentrate the platelets, and then injected into the areas of the scalp where hair thinning or loss is occurring. The process is minimally invasive and is intended to encourage the healing and regeneration of hair follicles, promoting thicker, healthier hair growth.

Pre-Treatment Questions

Have you previously undergone any PRP treatment or other hair restoration procedures (e.g., hair transplant, laser therapy)?

Yes

If yes, please specify details of the procedure and your experience:

Do you have any current or previous medical conditions that might affect your hair growth, such as hormonal imbalances, thyroid disorders, or autoimmune diseases?

Yes

If yes, please explain:

Are you currently taking any medications, including over-the-counter drugs, supplements, or topical treatments that might affect your hair or scalp (e.g., blood thinners, corticosteroids, finasteride, minoxidil, etc.)?

Yes

If yes, please list the medications and supplements you are taking:

Do you have any history of scalp infections, conditions such as eczema, psoriasis, or dermatitis, or any allergies to anesthetics or blood products?

Yes

If yes, please provide further details:

Have you had any recent surgeries, injections, or treatments to the scalp, including Botox, dermal fillers, or any other cosmetic treatments?

Yes

If yes, please provide details:

Do you have any history of blood clotting disorders, or are you on any medications that may affect your blood’s ability to clot (e.g., blood thinners, anticoagulants)?

Yes

If yes, please specify the condition or medication:

Are you pregnant or breastfeeding, or do you plan to become pregnant in the near future?

Yes

Have you had any allergic reactions to PRP therapy or any ingredients commonly used during the treatment (e.g., lidocaine, hyaluronic acid, or other numbing agents)?

Yes

If yes, please explain:

Treatment Procedure Understanding

Do you understand that the PRP procedure involves drawing a small amount of your blood, processing it to concentrate the platelets, and then injecting it into your scalp in areas where hair thinning or loss is present?

Yes

Are you aware that PRP therapy typically requires multiple sessions to achieve optimal results, and that hair regrowth may take several months to become noticeable?

Yes

Do you understand that results of PRP therapy may vary depending on individual factors such as the degree of hair loss, age, and the overall health of your scalp and hair follicles?

Yes

Are you aware that while PRP is generally considered a safe and effective treatment, there are potential risks, side effects, and complications, including but not limited to: discomfort, swelling, redness, bruising, temporary hair shedding, and, in rare cases, infection?

Yes

Do you understand that you may need to follow specific aftercare instructions, including avoiding strenuous exercise, limiting sun exposure, and refraining from touching or massaging your scalp for a certain period after the procedure to minimize the risk of complications and achieve optimal results?

Yes

Potential Risks & Side Effects *

Temporary swelling, redness, or tenderness at the injection site

Mild bruising at the injection points

Mild discomfort or headache due to the injection procedure

Infection (very rare but possible)

Temporary hair shedding or “shedding phase” after treatment (known as “hair shedding” or “dormant hair”)

Allergic reaction to the injected substances (rare)

Post-Treatment Care

Do you agree to follow all post-treatment care instructions to ensure the best possible results, which may include: *

Avoiding direct sun exposure and using sunscreen on the treated areas for several days?

Refraining from washing your hair or using hair products immediately after the treatment?

Avoiding strenuous physical activity or excessive sweating for at least 48 hours following the procedure?

Avoiding massaging or manipulating the scalp for a period of time to prevent affecting the PRP’s absorption and effects?

Consent & Acknowledgment

By signing this form, I acknowledge and consent to the following: *

I have provided complete and accurate information about my medical history, current medications, allergies, and any conditions that may affect the treatment.

I understand the nature of the PRP hair loss treatment, including potential risks, benefits, and the possibility that results may vary.

I am aware of the pre- and post-treatment care instructions, and I agree to follow them to help ensure the best results.

I understand that the procedure involves drawing blood from my body and injecting the PRP into my scalp, and I give my consent for this procedure to be performed.

I acknowledge that, while PRP therapy has been shown to be effective for many patients, there is no guarantee of success, and individual results may vary.

I agree to contact my practitioner immediately if I experience any adverse effects following the procedure.

Date: *

Client Signature: *

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Practitioner Name: *

Practitioner Signature *

Clear

I agree to terms & conditions provided by the company.

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