Microneedling with Platelet Riche Plasma (PRP) Consent Form
I authorize Beautox Bar LLC or any delegates associates to perform microneedling treatment
with or without platelet rich plasma (PRP). I understand that this procedure is elective.
Microneedling treatment with or without PRP is not recommended for those who:
• Have herpes, active cold sores, psoriasis, warts, raised moles, sun burn, or active skin
infection the day of treatment
• Have had laser, waxing, or a chemical peel in the last week
What to expect:
• Depending on the area of your face or body being treated, the procedure is well-‐
tolerated and in some cases virtually painless, feeling only a mild prickling sensation.
• You can have topical anesthetic applied to your skin prior to treatment to reduce or
eliminate pain or discomfort.
• Your skin will be pink or red after treatment, much like a sun burn for a few hours
• Minor bleeding and bruising is possible depending on the number of times it is pressed
across an area.
• Approximately 20cc of blood are drawn from the patient in the same way blood samples
are taken for lab tests in order to obtain the PRP.
• Tubes of blood are placed in centrifuge where it is spun in order to separate the red
blood cells from the PRP. The PRP is either injected or applied topically onto the skin.
• Do not wash treated area for 24 hours.
• Read and follow the post-‐treatment instructions.
• Side-‐effects are minimal with this type of treatment and typically include minor flaking
or dryness of the skin with scab formation in rare cases.
• Hyper-‐pigmentation can occur very rarely and usually resolves after a month.
• Temporary redness and mild-‐sunburn effects may last up to 4 days.
• Crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the
The benefits and risks of the procedure have been explained to me and I accept these benefits
Patient Name (Print) _____________________________Patient Signature _________________________