Name
*
First Name
Last Name
Date Of Birth
*
Phone
*
(###)
###
####
Emergency Contact
*
Email
*
Are you okay with Paige taking photos that she could share for marketing purposes?
Do you have any known allergies (medications, foods, etc.)?
Please answer the following questions to the best of your knowledge:
Are you currently taking any medications (prescription or over-the-counter)?
Please answer the following questions to the best of your knowledge:
Have you taken any blood-thinning medications or supplements in the past week (e.g., aspirin, ibuprofen, fish oil, vitamin E)?
Please answer the following questions to the best of your knowledge:
Have you had any cosmetic procedures in the past 4 weeks (e.g., Botox, fillers, chemical peels)?
Are you currently pregnant or breastfeeding?
Do you have any history of keloid scarring or poor wound healing?
Do you have any autoimmune diseases or chronic medical conditions?
Have you used Accutane in the past year?
Acknowledgments:
*
Please Check All To Consent
Risks and Complications:
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I understand that, like all cosmetic procedures, PRP Microneedling carries certain risks, which include but are not limited to:
Redness, swelling, or irritation at the treatment site
Bruising or bleeding at the injection points
Risk of infection
Temporary discoloration or hyperpigmentation
Allergic reaction to any topical or PRP application
Flare-up of cold sores (if prone to them)
Temporary tightness or discomfort post-treatment
I acknowledge that individual results vary and that multiple sessions may be necessary to achieve the desired outcome.
Consent for Treatment:
*
By signing below, I acknowledge that I have read and understood the information provided to me regarding PRP Microneedling. I have had the opportunity to ask questions and all of my concerns have been addressed to my satisfaction. I give my voluntary consent for this procedure, and I assume all risks associated with the treatment.
