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Congrats on being selected as a model for our upcoming Platelet Rich Plasma (PRP) Course

Please read and sign the below consent form to be enrolled in a time slot for the course. 

CONSENT FOR TREATMENT:  Platelet Rich Plasma (PRP) Consent

Sign our consent form

Cancellation Policy

If the cancellation occurs within 14 days of the course date, a $100 cancellation fee will apply. This policy is in place to ensure the smooth operation of our courses, as last-minute cancellations can potentially impact the live injection experience for a student if the spots can't be filled.

Section 1

DESCRIPTION OF TREATMENT

This treatment involves the collection of your blood (approximately 20-60 ml), then your blood is spun down using a centrifuge to separate out the plasma and platelet portion using the separator gel as a special filter. The PRP portion of your blood is then injected back into your skin to stimulate new collagen production, and to re-energize your cells into rejuvenating themselves. The product injected is 100% your own blood by-product (autologous).

Section 2

SIDE EFFECTS

You will likely experience mild to moderate swelling of the treated area. This will last for about 12-24 hours; ice or cold compresses can be applied to reduce swelling if required. You may notice a tingling sensation while the cells are being activated. In rare cases, skin infection may occur, which is easily treated with an anti-biotic.

CONTRAINDICATIONS

You should not have PRP treatment done if you have any of the following conditions: Skin conditions and diseases including: Facial cancer, past and present. This includes SCC, BCC and melanoma, systemic cancer, chemotherapy, steroid therapy, dermatological diseases affecting the face (i.e. porphyria), blood disorders and platelet abnormalities, anticoagulation therapy (i.e. Warfarin)

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, critical thrombocytopenia, hypofibrinogenemia, hemodynamic instability, sepsis, chronic liver disease, hepatitis or any acute or chronic infections?
Are you currently taking any of the following medications: Aspirin, Anti-inflammatory such as Nurofen, Voltaren, Diclofenac, or Naproxen, St John’s Wort, Garlic, Vitamin E?
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?

Section 3

I understand that due to the natural variation in quality of 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 6 sessions to obtain my desired outcome.

 

This procedure and side effects has been explained to me including alternative methods as have the advantages and disadvantages.

I am advised that thought 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 occur over time.

 

I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions have been answered in a satisfactory manner and that all blanks were filled in prior to my signature.

By registering, paying and attending the AESTRA Institute course, you understand that you may be photographed, filmed or videotaped and you expressly give the AESTRA Institute, its owners, agents and principals the right to take pictures and/or recordings of you and use your likeness, image, photo without compensation, for broadcast, display, and exhibition in any medium for purposes of advertisement and education and to put the finished pictures /recordings to any use without limitation. You further expressly release AESTRA Institute from any or all claims or actions arising out of or resulting from any use of your image. However, the AESTRA Institute shall not be obligated to use your image.

 

***By consenting to this treatment, I agree, affirm and represent that I am waiving my right to seek any recovery for any damages that occur as a result of receiving this treatment whether such damages are as the result of an inherent risk or latent or unintended risk including any damages that may occur which are not the result of a known or expected risk. I waive any and all recovery for damages of any kind whatsoever.***

 

I have been informed and I understand that the practitioners who will perform this procedure may or may not be licensed to practice in the state of Florida. I have been informed and understand that Aestra Institute and Denise Merdich have not reviewed or investigated whether the practitioners performing this procedure have appropriate licensure within the state of Florida. Despite knowing that the practitioner(s) performing my procedure may or may not be licensed in Florida, I am voluntarily giving consent for the practitioners who may be licensed in other states to practice medicine, nursing, advanced registered nurse practitioners and physician's assistants to perform the procedure on me.

Thank you for your consent!

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