PRP (Platelet Rich Plasma) Information, Assessment and Consent Form

PRP stands for platelet-rich plasma, a component in blood that is rich in a type of cell called platelets.

PRP injections are currently used for three predominant indications in dermatology;

Male and female pattern hair loss (ie hair thinning)
Anti-aging cosmetic treatments
Wound healing after facial procedures

If you have previously seen a dermatologist at this practice, please select your dermatologist *

There are two types of PRP available at Melbourne Skin & Dermatology.

1. Standard PRP: This is the most common type of PRP offered in clinics and the yield of PRP is moderate ($490 per treatment).

2. High-density PRP (HD-PRP): This yields a much higher concentration of platelets and growth factors ($690 per treatment).

How is the procedure performed?

Blood is drawn from the patient which is then spun down. This process takes approximately 15 mins. Platelet rich plasma hair loss treatments are then performed by multiple injections directly into the scalp. When PRP is used to aid in acne scarring or rejuvenation treatments (such as the PRP facial), the product is applied topically after laser, radiofrequency microneedling or standard microneedling. Treatments are usually performed monthly for 3 months and again at the 3 and 6 month marks to achieve maximal results. Maintenance treatments every 6 to 12 months are optional.

Is the procedure painful?

Injections of PRP into the scalp can be painful. We use ice and a vibrating anaesthetic device on all patients when PRP is injected into the scalp. Despite these meaures, the treatment can still be uncomfortable.

We highly recommend use of Nitrous Oxide Gas (laughing gas) during the procedure for additional comfort. This is available to you at $65 per set of injections.

Pre-procedure care

Patients are encouraged to be well hydrated to aid in blood collection.

1. Standard PRP: This is the most common type of PRP offered in clinics and the yield of PRP is moderate ($490 per treatment).

2. High-density PRP (HD-PRP): This yields a much higher concentration of platelets and growth factors ($690 per treatment).

Please select the type of PRP you would like to proceed with *

Standard PRP - $490 per treatmentHigh Density PRP - $690 per treatment

Would you like to have Nitrous Gas on the day of treatment? *

YesNo

You can drive afterward as the effects of nitrous gas are immediate and temporary. This adds to your cost by $65.

Who is completing this form? *

I am the patientI am a parent of the patientI am a guardian of the patient with power of medical attorney

Patient details

Parent/Guardian details

Are you known to have low platelet count? *

YesNo

Are you taking Warfarin, Clexane or Heparin? *

YesNo

Do you have chronic liver disease? *

YesNo

Have you had any form of cancer in the past (or currently)? *

YesNo

Unfortunately, PRP treatments can not be offered to you for safety reasons. Please close this window and contact us if you would like to discuss this further.

Have you ever had PRP treatments in the past? *

YesNo

What was the reason for treatment (e.g. male or female pattern balding, facial rejuvenation)? *

What area was treated? *

Have you encountered any complications after your PRP treatments? *

How many treatments have you had?

How have treatments been performed? *

InjectionMicroneedling

When was your last treatment? *

Where have you previously had these treatments? *

Potential Risks

I understand I may experience pain, swelling and bruising in the treated area. *

I understand and accept the potential risks of skin injury & infection *

I have had ample opportunity to consider and discuss the treatment and I have had all my relevant questions answered to my satisfaction. *

Declaration

I understand I may need multiple treatments with the cost of each subsequent treatment being the same as the first procedure unless otherwise advised in written format. *

I understand that I may not respond to treatment or have an incomplete result, even after multiple treatments. *

I understand that there is no guarantee that this treatment will work for my condition. *

I understand that the same problem may come back in the future. *

I understand that this is an elective procedure and I am aware that there may be alternative treatments (including not treating at all). *

I understand that it is my responsibility to follow the post-treatment instructions. *

I have read the fee information and agree to pay the fee in full on the same day as the service. *

Full name of parent/guardian completing this form *

Signature of guardian/parent *

Clear

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Signature of patient *

Clear

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Today's date *

I have completed this form accurately and request that the procedure be carried out. *