Introduction

This consent form is intended to ensure that the patient understands the potential risks, benefits, and possible complications of Platelet-Rich Plasma (PRP) therapy for hair loss. PRP is an autologous treatment using the patient’s own blood components to stimulate hair growth. While generally considered safe, it may not be suitable for individuals prone to keloid formation, as injections and microtrauma to the scalp could potentially trigger excessive scar tissue development.

While many clients achieve favorable results, outcomes can differ from person to person.

Medical Information

1. Have you ever experienced severe allergic reactions, such as anaphylactic shock?

Yes

No

2. Do you have a history of keloid or hypertrophic scarring?

Yes

No

3. In the last 10 days, have you used Aspirin, Warfarin, other anticoagulants, or medications/supplements that might affect bleeding?

Yes

No

4. Do you have any medical conditions such as angina, epilepsy, hepatitis, Aids , receiving steroids, undergoing Chemo or radiotherapy or having any autoimmune diseases? If yes, please specify.

Yes

No

If Yes, specify

5. Are you currently pregnant or suspect you might be pregnant?

Yes

No

6. Are you breastfeeding?

Yes

No

By ticking the box, I confirm that, to the best of my knowledge, the medical history I have provided is accurate, and there are no additional health concerns I need to disclose.

Acknowledgment of Expectation

I acknowledge and understand that:

PRP therapy is designed to promote hair growth, but results are not guaranteed ,however, we expect good results.
The effectiveness of PRP therapy varies among individuals, and there is a possibility that you may not experience noticeable improvement within six months of treatment depending on the stage of the hair loss, age, and medical state and sometimes lifestyle.

Acknowledgment of Risk

I have been informed about the possible risks and side effects of PRP therapy, which include but are not limited to:

Development of keloid or hypertrophic scarring at injection sites
Scalp irritation, redness, or inflammation
Temporary or permanent discomfort, pain, or sensitivity
Infection at the injection site
No guarantee of hair regrowth or improvement

Contraindications

I understand that PRP therapy is not suitable for individuals with certain conditions, including but not limited to:

Active cancer or a history of blood-related disorders.
HIV infection.
Thrombocytopenia (low platelet count).
Ongoing anticoagulant therapy.
Active infections or chronic skin conditions at the treatment site.
Conditions or treatments that suppress the immune system.

Instead , one can book StemCell Streatment

Liability Waiver and Release

I understand and agree that:

I hereby release, indemnify, and hold harmless Trinity Trichology Clinic and any affiliated staff or practitioners from any liability, claims, or damages arising from the PRP procedure, including but not limited to keloid formation, hair loss, scarring, or any other unexpected reactions.
Trinity Trichology Clinic cannot guarantee specific results from PRP therapy.
The clinic is not liable for any complications or dissatisfaction with the treatment outcomes.
Failing to disclose accurate medical information could compromise my safety during the procedure.

Consent and Agreement

• I have read and fully understand the nature of the PRP treatment, its risks, and possible complications.

• I acknowledge that no guarantees have been made regarding the success of this procedure.

• I accept full responsibility for any consequences and agree not to hold Trinity Trichology Clinic legally responsible for any adverse effects related to the treatment.

• I have been given the option to decline treatment and seek alternative solutions.s.

By ticking below, I voluntarily consent to undergo PRP therapy for hair loss.

Tick here to consent