Free PRP Therapy Consent Form Template

Informed Consent for Platelet-Rich Plasma (PRP) Therapy

Patient Informed Consent Documentation

Patient and Provider Information

What PRP Therapy Involves

Platelet-rich plasma (PRP) therapy uses the patient's own blood to create a concentrated solution of growth factors and platelets. The process has three steps: (1) A small amount of the patient's blood (usually 20 to 60 mL) is drawn from a vein in the arm, the same way a routine blood test is taken. (2) The blood sample is placed in a centrifuge machine that spins at high speed to separate the blood into its components. The platelet-rich layer is isolated and drawn into a syringe. (3) The PRP solution is injected into the target area (such as the scalp for hair loss, or the face for skin rejuvenation) using a fine needle. Because PRP is made from the patient's own blood, the risk of allergic reaction is very low. The procedure usually takes 45 to 90 minutes in total. Most patients need a series of 3 monthly sessions followed by maintenance injections every 4 to 6 months.

Blood Draw Authorization

I authorize the treating provider to draw the volume of blood stated above from my arm for the purpose of preparing PRP. I understand that the blood draw is performed by trained staff using sterile single-use equipment. I understand that this is an autologous procedure, meaning the blood drawn and the PRP prepared from it are used only for me and are not transferred to any other person.

Pre-Treatment Health Screening

Regulatory Status Notice

I understand that PRP therapy for aesthetic purposes (such as facial skin rejuvenation and hair restoration) is not FDA-approved as a stand-alone treatment. The FDA has cleared PRP systems and devices for processing blood, but has not approved PRP as a drug or medical device for cosmetic indications. PRP injections for aesthetic use are performed based on physician judgment and a growing body of clinical research evidence. This does not mean the treatment is unsafe; it means the level of regulatory review that applies to approved pharmaceutical drugs does not yet apply to autologous PRP. I have been informed of this status and consent to proceed.

Risks and Possible Side Effects

Alternatives to PRP Therapy

What to Expect from Results

For hair restoration, most patients begin to notice less shedding after 2 to 3 months and new hair growth after 4 to 6 months. For skin rejuvenation, improvement in texture and tone usually becomes visible 4 to 6 weeks after treatment and continues to improve over the following months. Results vary significantly between individuals. Maintenance sessions every 4 to 6 months help sustain results. PRP does not stop the underlying cause of hair loss; it supports the hair follicles but must be combined with an appropriate medical treatment plan if a diagnosed condition is causing the hair loss.

Post-Treatment Care Instructions

For the 24 to 48 hours after treatment: (1) Avoid washing the scalp or face for at least 6 hours after scalp or facial PRP injections. (2) Do not apply styling products, hair dye, or chemical treatments to the scalp for at least 48 hours. (3) Avoid strenuous exercise, saunas, and hot baths for 24 hours. (4) Do not apply ice directly to a scalp injection site, as cooling may affect growth factor activity. (5) Avoid anti-inflammatory medications such as ibuprofen for 48 hours after treatment, as inflammation is part of the intended healing response. (6) Contact the clinic if you notice unusual swelling, persistent pain, or any sign of infection.

Right to Refuse Treatment

The patient has the right to decline this procedure or to stop after the blood draw but before the injection is performed. If the patient stops after the blood draw, the PRP prepared from their blood will be discarded. The patient is responsible for the cost of the session up to the point of stopping, as the blood draw and centrifuge processing have been performed.

Patient Understanding

I confirm that I have read this consent form or had it explained to me. I have asked questions about the blood draw, the preparation process, the injection sites, and the expected results. All my questions have been answered. I understand that PRP is not FDA-approved for aesthetic use, that results vary between individuals, and that multiple sessions are usually needed.

Language Access

If English is not your main language, please ask for an interpreter before signing. This form must be fully understood before you agree to treatment.

Copy of Consent

I acknowledge that I have been offered a signed copy of this consent form for my records.

Patient Authorization

I voluntarily agree to receive PRP therapy as described in this form. I authorize the blood draw and the preparation and injection of my own PRP. I confirm that I have disclosed all relevant medical history, medications, and conditions. I understand and accept the risks, limitations, and regulatory status of PRP therapy for aesthetic use.

Signatures and Verification