Ashmore Osteopathic Group
Patient Information Consent Form for Autologous Platelet-Rich Plasma (PRP) Treatment
Description of treatment:
This treatment involves the collection of your blood, which is then spun down using a centrifuge to separate the plasma and platelet portions. The PRP portion of your blood is then injected back into the region of your musculoskeletal condition as the method of treatment. The product injected is 100% your own blood by-product (autologous).
If you have any questions please do not hesitate to ask your treating practitioner or reception staff.
Name: …………………………………………………………………………………….
Consent to receiving an autologous, PRP injection for the management of my musculoskeletal condition.
I have been informed on the process required to harvest the PRP, patient suitability, possible adverse reactions and the risks associated with PRP injections.
Contraindications:
You may not be a candidate for PRP treatment if you have any of the following conditions:
Systemic cancer, chemotherapy, steroid therapy, blood disorders and platelet abnormalities or anticoagulation therapy (i.e. Warfarin)
Comments: ……………………………………………………………………………………………
If you are unsure about any of above mentioned conditions, please ask!
Have you ever been told that you suffer from or suspect you suffer from: Platelet dysfunction syndrome, thrombocytopenia, chronic liver disease, Hepatitis or any acute or chronic infections? YES / NO (circle one)
If yes, please state: ………………………………………………………………………………………………
Are you currently taking any of the following medications: Aspirin, Anti-inflammatory such as Nurofen, Votaren, Diclofenac, or Naproxen? YES / NO (circle one)
Have you had COVID Vaccination in last 10 days? YES / NO
………………………………………………………………………………………………
Are you currently taking, or have you recently taken (within 14 days) Vitamin E, or Fish Oil supplements that could have a thinning effect on your blood?
YES / NO (circle one) If yes, please state:
………………………………………………………………………………………………
Side effects: Platelet Rich Plasma (PRP) is prepared from autologous blood so there is no risk of developing a growth of tumour or cancer. Adverse effects are rare but as with any injection procedure there is always the small risk of needle flare or infection.
Severe complications such as infection are very rare. If you experience worsening severe pain and swelling in the region after 2-3 days hours post-injection treatment, contact this office immediately on (07) 5597 5711 or SMS +61 412 546 162 or an emergency centre after hours.
Is It Painful: It is usual that you may feel some pain during and following the injection. This may be due to the PRP procedure and/or needle flare at the injection site.
You will likely experience mild to moderate pain/swelling of the treated area, that will last upto 36 hours; ice or cold compress can be applied to reduce swelling if required. It is preferred that you use paracetamol for pain relief or paracetamol combined with codeine should you require something stronger.
Client Consent
I understand that due to the natural variation in quality of PRP (Platelet Rich Plasma), results will vary between individuals.
I understand that although I may see a change after my first treatment; I may require a series of up to 3-5 sessions to obtain my desired outcome.
The procedure and side effects have been explained to me including alternative methods; as have the advantages and disadvantages.
I am advised that although good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment.
I am aware that the PRP treatment is not permanent as natural degradation will continue to occur over time.
I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it.
I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner and that all blanks were filled in prior to my signature.
When completing the medical questionnaire, I have answered the personal medical history questions fully and to the best of my ability.
Name ………………………………………………………………………………………
Signature ………………………………………………………………………
Date ………………………………
Note:
In undertaking the PRP treatment there is a strict protocol which is followed for patients who are considered for this treatment modality. This protocol is monitored and performed under the guidance and professional supervision of a medical practitioner working within this scope of practice.
*DISCLAIMER: Like all medical procedures, they do have a success and failure rate. All patient reviews on this site should not be interpreted as a statement on the effectiveness of our treatments for anyone else.