PRP, Face, Neck, Chest, Hands, Hair Restoration or Eyebrow Consent

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Patient Information

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PRP, Face, Neck, Chest, Hands, Hair Restoration or Eyebrow Consent

The Natural Place & Integrity Medical PRP Procedure Informed Consent

I consent to the medical procedures outlined below to be performed by The Natural Place Med spa (medical professional) and his/her staff, associates, or assistants to whom the medical professional(s) performing the procedure may assign designated responsibilities.

Voluntary Procedure. The proposed medical/surgical procedure is an elective, voluntary procedure. The procedure has been explained to me in terms that I understand.

Nature of Procedure. The nature and extent of the procedure to be performed, which involves inserting a needle into various areas of the body and injecting Integrity Amniotic Fluid, amniotic derived product. The processed human tissue product will be injected into the treatment area.

  • Face, Neck, Chest, or Hands Rejuvenation Injections– PRP (Platelet-Rich Plasma) is a type of regenerative therapy that harnesses the body’s innate ability to heal itself, while turning back the hands of time. Aesthetic medicine practitioners are using PRP to reduce facial wrinkles and deep creases, plump up sagging skin, improve the tone and texture of the skin and diminish acne scar the effects of PRP are not permanent but effects can last up to 18 months in an average with a maximum of 2years as the longest reported effect. However, most may resort to a re-touch of the treatment once a year. If combined with fractional lasers more efficacy is increased.
  • Does it hurt? Most patients experience the PRP as virtually painless
  • Cutting-edge technology? Yes. Used in conjunction with a patient’s own biological cells it naturally promotes skin health.
  • What are the risks? There is no risk of an allergic reaction with PRP therapy because the enriched plasma has been produced from the patient’s own blood. A concentrated amount of white blood cells makes up part of the PRP which are the body’s natural defenders against infections. Infections are therefore extremely rare.
  • Are my red blood cells re-injected? No. The red blood cells are separated from the platelets and only the enriched plasma (PRP) will be injected into your skin.
  • How long does PRP treatment takes? The actual procedure normally takes between 30 and 60 minutes, depending upon the area’s being treated.
  • When can I go back to work? Some redness may be visible on the treated areas following the procedure and some minor bruising. These will disappear a couple of days after treatment.
  • Do I need to repeat this treatment? We advise 3 to 4 treatments initially, with a rest period of 6 weeks in between for optimal results. After this, we recommend a yearly or semi-annual refresher treatment to maintain the skin depending upon skin type and treatment goals.

PRP For Eyebrows Tired of filling in your eyebrows every morning just to get that full, thick shape? If regrowing hair in the eyebrows after years of plucking and waxing or wrinkles or scars are getting in the way of having the perfectly shaped brow, then PRP might be just what you need makes your eyebrows look amazing and natural without the extra time and money spent on penciling in or otherwise treating your eyebrows. What Is PRP for Eyebrow Restoration? Platelet-rich, or PRP, is a non-surgical procedure that encourages hair growth at the injection site. First, a small amount of blood is drawn from the patient and put into a centrifuge that separates the blood from platelets. Your platelet-rich plasma is then added to a premixed serum that helps stimulate regrowth. The final product is then injected back into the skin by a micro-needling tool. How Long Will It Take to See Results, and How Long Do They Last? Hair growth happens in cycles and takes time, so results will not be immediately visible. You should begin to see results over the course of three to four months. Since the PRP is stimulating new hair growth, the results are permanent. Treatments should be done over the course of one year, and it is recommended that you have at least six treatments for optimal results. While hair is growing back in naturally, you may experience hair growth in an unwanted area around the brow. But try not to pluck the new hairs. This may cause you to need more treatments to get your brows just the way you want them. Why Wait, Get Started Now! Ready to throw away the eyebrow pencil and stop wasting your precious time and money? PRP for eyebrow restoration is the solution. You’ll have thicker, fuller, natural brows that will make everyone wonder how you did it. PRP can also help to soften your features and allow you to age beautifully.

Hair Restoration-3-4 treatments or possibly one every year as a maintenance requirement, 4-6 weeks apart, suggested Vitamins and hair restoration line for daily use to maintain results and regrowth of hair.. Resume washing hair & exercise 24 hours after procedure

PRP can help accelerate the growth while also thickening existing hair. Recent studies have suggested that applying PRP to the scalp can address androgenic alopecia (male pattern baldness) some studies show 18 months or longer on hair longevity.

Risks. The procedure may be classified as innovative or experimental. The most frequently occurring risks of the procedure involved, and those risks which are unlikely to occur but which may involve serious consequences, include but are not necessarily limited to the following: Discomfort, severe pain, bruising, inflammation, injury and numbness at the site of injection; fatigue, dizziness, or light-head feeling after injections; or fainting or loss of consciousness during the procedure. Uncommon reactions include allergic reaction to disinfectants or medications used, histamine reaction, persistent postoperative edema, fainting, pigmentation change, or sensory nerve damage. General risks may include pain, scarring, bleeding and infection.

PRE- TREATMENT INSTRUCTIONS FOR PRP PROCEDURES: 1. Avoid the following for at least 1 week prior to your procedure: • Do not use any prescription or over the counter anti-inflammatory medicines such as NSAIDS (Ibuprofen, Motrin, Aleve, Naprosyn, Aspirin, Voltaren, Diclofenac, Meloxicam, Mobic, or Celebrex) for 4 days prior and 7 days after the procedure, or as stated by your primary care physician– Tylenol is allowed • Certain nutritional supplements (Gingko, Garlic, Vitamin E, Vitamin A, Flax Oil, Curcumin and other anti-inflammatory nutrients) • Systemic Steroids (prednisone, dexamethasone) must be discontinued 2 weeks prior to and 4 weeks after PRP injections or as stated by your primary care physician. • Alcohol, Caffeine and Cigarettes 3 days prior to treatment • Discontinue blood thinning medications or supplements (Plavix, Coumadin, Heparin) one week prior to treatment unless you are taking them for a medical condition. If so, please consult your primary care physician to see if you are a candidate. • If you are taking broad beta-blockers such as Inderal (propranolol), please contact your primary care physician as this medication may need to be changed in advance of the treatment. 2. Prescription medications including heart and blood pressure medication should be taken as prescribed right up to and including the day of and the day after your treatments. 3. Hydrate well the day before and the day of the procedure for ease of blood draw. 4. You may start Arnica 5 pellets, 3 times a day starting 2 days before, and continuing the day of and for 2 days after the procedure to decrease the risk of bruising. 5. Ensure you have not been on Accutane in the past 6 months. 6. If you believe that you may have a medical condition or are taking any medications not listed above that could interfere with treatment.

Notify your physician prior to signing this consent if any of the following apply to you:

  • Cold sores (or history), warts, open skin lesions, sunburn, extreme sensitivity, dermatitis, rosacea
  • Blood thinning medications
  • Accutane or generic within the past year
  • Pregnant or Breastfeeding
  • Received chemotherapy or radiation therapy
  • Collagen vascular disease
  • Eczema, psoriasis, or dermatitis
  • Hemophilia/ bleeding disorders
  • Keloid/ hypertrophic scarring
  • History of autoimmune disease or any condition that may weaken your immune system
  • THE DAY OF THE PROCEDURE: 1. Blood is drawn and PRP is processed. 2. Topical Anesthetic is applied to the treatment area for 20-30 minutes. 3. Specific procedures are listed below: • For the PRP facial: The Micro needling pen and/or hydra needle is used to stimulate the skin tissue. PRP is then placed on the surface and can penetrate easily into the areas being treated with the device. • For the PRP Face, neck, chest or hand Lift: Fillers are injected into the areas of concern, then is followed by injecting your own PRP. PRP is strategically injected into the area painlessly. • PRP for the Scalp: A topical anesthetic is applied to the treatment area for 20-30 minutes. PRP is processed and injected into the treatment area. Afterwards a micro needling pen or hydra needle may be used to stimulate the area and the remaining PRP is rubbed into the scalp.

Patient Representations. I have made the following assurances to the medical professional prior to this procedure:

  • I have informed the provider of any known allergies to drugs or other substances, or of any past reactions to anesthetics. I have informed the doctor of all current medications and supplements.
  • I understand that I should only apply products recommended by my clinician pre and post treatment.
  • I have avoided the following products/procedures at least three days prior to treatment: topical prescriptions including but not limited to Retin-A, Tretinoin, Differin, Tazorac, abrasive scrubs or other exfoliating products. I have not had any cosmetic injections within the last two weeks.
  • I have followed my clinician’s pre-treatment instructions and will follow my clinician’s post-treatment instructions
  • During the course of the treatments, notify our staff of any changes to your medical history, health status, or personal activities that may be relevant to your treatment.

Hold Harmless. I hereby agree, to the extent allowable under the law, to release Integrity, LLC from liability & The Natural Place Med spa for any present or future claim(s) or legal action(s) for any harm resulting from in connection with the aforementioned procedure or product(s) employed therein.


I was given the opportunity to ask any questions I have regarding the procedure and I have had those questions answered to my satisfaction.

I understand that I may consult or could have consulted with another physician or medical professional about this procedure.

I understand that I have the right to refuse any medical treatment at any time prior to its performance.

I am aware and I acknowledge that no guarantees have been made to me concerning the results of this procedure.

I authorize that a medical professional in training, a representative or technician from a medical device company may be present at the procedure.

Photography or video may be utilized for medical, scientific, training, marketing, or educational purposes, provided my identity is not revealed in the photo or text. Any Personal Health Information obtained from this procedure and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law.

I acknowledge that I have read (or had read to me) and fully understand the above information.

I hereby authorize my physician to perform the above discussed procedure.

Amniotic Fluid Volume: _____________________________Amniotic Fluid Lot #: _______________________________

Amniotic Fluid Exp Date: ____________________________Amniotic Fluid Serial Number: ________________________

POST- TREATMENT INSTRUCTIONS FOR BEST RESULTS: 1. Expect mild inflammation, redness, swelling for a few days. 2. Bruising may last several weeks. 3. Avoid the sun & use a physical sun block daily to prevent permanent discoloration. 4. Avoid manipulating or pressing on the treated area(s) for 48 hours (including having other treatments done). If you are concerned with any lumps felt, please call the office for a follow up appointment within 48 hours. 5. Try to sleep on an incline and not on your belly. 6. Avoid any massages to the areas treated. 7. After PRP treatment for males and females, sexual activity can be resumed as before. There are a couple of devices that may need to be used to ensure success. 8. After a scalp treatment, you can wear a laser cap for 20 minutes every other day for 6 weeks. 9. Eat healthy and hydrate very well (at least 64 ounces of water daily) 10. You may wear a hat immediately after your PRP treatment. 11. For the first 3 days, use shampoo that is pH balanced. 12. It is normal to experience bruising, redness, itching, swelling and/or soreness that may last from 2-5 days following your procedure. If you experience any pain or discomfort, you may take Tylenol or other Acetaminophen containing products as directed. 13. Avoid the following for at least 1 week: • Retin A/ Tretinoin or retinol containing products • NSAIDS (Ibuprofen, Motrin, Aleve, Naprosyn, Aspirin)- Tylenol is allowed for pain reduction • Certain nutritional supplements (Gingko, Garlic, Vitamin E, Flax Oil, Curcumin, and other anti-inflammatory nutrients) • Systemic Steroids (prednisone, dexamethasone) • Avoid Alcohol, Caffeine and Cigarettes 3 days post treatment • You may wash your hair the day after your PRP treatment (avoid resuming Minoxidil products or hair coloring or straightening for 3 days. • Do not wet your hair for at least 3 hours after your treatment. • Do not use any hair products for at least 6 hours after your treatment. • Avoid saunas, steam rooms, and swimming for 2 days after your treatment. • Avoid vigorous exercise, sun and heat exposure for at least 2 days after your treatment. • Do Not touch, press, rub or manipulate the treated area(s) for at least 8 hours after your treatment • Avoid applying ice on the injected area as ice acts as an a

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