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:    

•   Are  pregnant  or  breast  feeding  
•   Have  herpes,  active  cold  sores,  psoriasis,  warts,  raised  moles,  sun  burn,  or  active  skin  

infection  the  day  of  treatment  

•   Have  been  taking  Accutane    
•   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  

following.  

•   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.    

•   Your  skin  may  feel  warm,  tight,  and  itchy  for  the  first  hours  after  treatment.      
•   Do  not  wash  treated  area  for  24  hours.  
•   Read  and  follow  the  post-­‐treatment  instructions.  

 

Possible  side-­‐effects:    

•   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.    

•   Milia  (small  white  bumps)  may  form;  these  can  be  removed  by  the  practitioner.  
•   Hyper-­‐pigmentation  can  occur  very  rarely  and  usually  resolves  after  a  month.    
•   Temporary  redness  and  mild-­‐sunburn  effects  may  last  up  to  4  days.  

•   Freckles  may  temporarily  lighten  or  permanently  disappear  in  treated  areas.    
•   Crusting,  itching,  discomfort,  bruising,  infection,  swelling,  and  failure  to  achieve  the  

desired  result.      

 

The  benefits  and  risks  of  the  procedure  have  been  explained  to  me  and  I  accept  these  benefits  

and  risks.      

 

Patient  Name  (Print)  _____________________________Patient  Signature  _________________________  

 

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