Allergies: Food? Drug/Drug Sensitivity? Other?
If Yes, please explain:
Are you currently taking any medications?
If Yes, please list:
Do you have any medical issues you feel are pertinent to your treatment(s)?
If Yes, please explain:
Do you smoke? If Yes, how much?
Do you drink alcoholic beverages? If Yes, how much?
Check if you have EVER HAD or CURRENTLY HAVE any of the following medical conditions:
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CANCELLATION
POLICY
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Dear Client,
Our goal is to provide quality service in a timely manner. This policy enables us to better utilize available appointments for clients in need of treatments.
Cancellation of Appointments
If it is necessary to cancel or reschedule your appointment, we require that you inform us 48 hours in advance. This time will be reallocated to someone who is in need of treatment. This is how we can best serve the needs of all our wonderful clients.
Client Initials:
Late Cancellations and No Shows
All appointments, including complimentary consultations and follow-ups, canceled or rescheduled with less than a 48-hour notice will result in a charge. This also applies to appointments made same day and appointments scheduled within 48 hours of the appointment time. If there is a late cancellation, late reschedule, or “No Show” you will either lose your deposit, lose your session, or be held to a $50 fee.
Client Initials:
Cancellation Due to Lack of Preparation for Appointment
All appointments, including complimentary consultations and follow-ups, that are cancelled by one of our providers while you are in our office due to a contraindication or other failure of preparation will result in a fee, as the time and resources for your appointment will have been specifically reserved for you and left inoperative otherwise. If you are sent home because you failed to follow pre-treatment instructions related to preparation for your appointment, you will either lose your deposit, lose your session, or be held to a $50 fee.
Client Initials:
How to Cancel Your Appointment
The best way to cancel an appointment is to call us at (760) LAVANDE. If you are unable to reach a staff member or it is after hours, you may email us at admin@lavande-spa.com, or text us at (760) LAVANDE.
My signature attests to the fact that I understand and agree to the information contained herein.
First Name: Last Name:
Signature:
Date:
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PRP THERAPY
CONSENT FORM
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Platelet Rich Plasma, also known as “PRP”, is a collagen induction therapy that can be administered via injection or microneedling, whereby a person’s own blood is used for skin rejuvenation purposes. A fraction of blood (30cc‐60cc) is drawn from the individual client (a relatively small amount compared to a blood donation which takes about 500cc), and the blood is spun down in a special centrifuge device to separate its components of red blood cells, platelet rich plasma, and platelet poor plasma. Platelets are very small cells in your blood that are involved in the clotting and healing process. The concentrated PRP (platelet rich plasma) is then extracted and activated with a small amount of calcium to allow the release of growth factors, which in turn amplifies the rejuvenation process. PRP is then injected into the designated treatment area(s) or allowed to seep into open channels in the skin that have been created by the microneedling process. When PRP is injected/infused into damaged areas, it causes a mild inflammation that triggers the healing cascade. As the platelets organize in the treatment area, they release a number of enzymes to promote healing and tissue responses, including attracting stem cells and releasing growth factors to repair damaged treatment area. As a result, new collagen and elastin begins to develop. As the collagen matures, it begins to shrink, causing the tightening and strengthening of the damaged area. When treating injured, sun and/or time damaged tissue, PRP can induce a remodeling of the tissue to a healthier and younger state.
BENEFITS OF PRP
PRP’s safety has been established for over two decades for its wound healing properties. Along with the benefit of using your own natural tissue therefore virtually eliminating the possibility of an allergic reaction, there is the added intrigue of mobilizing your own stem cells for regenerative benefits. PRP has been shown to have overall rejuvenating effects on the skin by improving skin texture, fine lines and wrinkles, increasing volume via the increased production of collagen and elastin, and by diminishing and improving the appearance of scars and other textural concerns. PRP is also used to stimulate hair growth in various forms of alopecia in both men and women. Other benefits include it having minimal recovery and down time, posing minimal risks, being quite tolerable, and offering natural-looking results.
CONTRAINDICATIONS
The following conditions are contraindicated with PRP Therapy treatment, and therefore any clients who suffer from the following conditions will not be good candidates for PRP Therapy treatment. Please notify Lavande aesthetic providers if any of the following apply to you.
- Active infections or disease (viral, fungal, bacterial)
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- Anticoagulants or bloodthinners (NSAIDS, ASA, etc.)
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- Recent ablative dermal procedures (laser, peel, etc.)
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- Severe metabolic and systemic disorders
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- Abnormal platelet function (blood disorders, hypofibrinogenemia, etc.)
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- Acute and chronic infections, allergies
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- Eczema, Psoriasis, Dermatitis
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- Skin-related autoimmune disorders
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- Raised lesions (moles, warts, etc.)
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- Keloids or hypertrophic scarring
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- Collagen vascular diseases
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- Pregnant or breastfeeding
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- Hemophilia or bleeding disorders
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- Actinic (solar) keratosis
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- Chemotherapy or radiation
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RISKS & COMPLICATIONS
Side effects and complications are usually minimal, but risks and complications do exist. Even if PRP Therapy is only minimally invasive, the needles still penetrate the skin which is an occurrence that is inherently associated with a number of health risks and concerns. These include:
- Pinpoint bleeding – Depending on the number of needles used on the skin either via injection or microneedling, there could be pinpoint bleeding. Higher needle counts provide for a glowly look and do not usually result in pinpoint bleeding, but lower needle counts tend to cause visible pinpoint bleeding. Bleeding at injection sites are also quite common, especially on the scalp
- Itching and irritation – This is a normal sensation, and should subside within hours after treatment
- Sensitivity, discomfort, pain – For days after microneedling, the skin will be quite sensitive as a result of the open micro-wounding in the skin, and will feel the most apparent when you are washing your face. Injection sites may also be painful or sensitive to the touch
- Erythema (redness/flushing) – After treatment skin will be red and flushed in appearance, but this is a normal side effect and part of the healing process. Redness should subside within 1-3 days (it will take longer with RF microneedling). This is normally also accompanied by sensitivity
- Swelling – Swelling is a normal side effect and part of the healing process. Swelling should subside within hours after treatment
- Bruising – This is a very rare, but could occur, and more likely through injection PRP
- Dryness, crusting, skin flaking – Skin will feel tight throughout the healing process, which is a normal side effect of collagen and elastin stimulation. Micro-wounded skin will also undergo a mild peeling process to dispose of the targeted damaged tissue
- Scarring (permanent or temporary) – Normal healing does not result in scarring, but scarring may occur. If you are prone to keloid scarring, scarring is highly likely to occur. Additional treatments will be needed to treat scarring, which becomes more likely if proper aftercare is not pursued
- Hyperpigmentation – Pigment or color change of the skin via hyperpigmentation is rare as the dermal penetration of microneedling treatment normally does not go so deep as to disturb the layer of skin containing melanocytes. However, if proper post-treatment aftercare is not rendered, it becomes much more likely (especially with RF microneedling)
- Infection – Infections are not common, but viral, bacterial, and fungal infections can occur anytime the integrity of the skin is compromised. With proper aftercare, this should be avoidable, but call our office immediately should an infection occur
- Allergic reaction to the solution used to process the blood – While your own tissue will rarely, if ever, do you harm or cause an allergic reaction, a reaction may still be had to the calcium and anticoagulant solution used to process the drawn blood
- Injury to a nerve and/or muscle – This is a very rare, but could occur with improper injection technique
- Nausea, vomiting – For more sensitive clients, this is a possibility
- Dizziness, fainting – For more sensitive clients, this is a possibility
- Hair shock – This is a rare side effect for PRP injections in the scalp, and the hair loss is usually temporary
I understand that I may experience these potential side effects. I understand that if I experience any of the above side effects, they are temporary and should resolve within a week at the latest. Please follow all post-treatment instructions to minimize the possibility of side effects, and reach out to Lavande providers in the case of severe side effects or questions about how to properly treat side effects.
INJECTION PROCEDURE
PRP may either be injected on its own into designated areas or mixed with a hyaluronic acid dermal filler prior to being injected. Injections are performed with a sterile fine needle, and every provider will have their own technique for injection. There may be multiple injection sites. Results for HA+PRP injections can be seen immediately with incremental improvement over time, while results for pure PRP injections will take about 4 weeks to become visible. As collagen and elastin is produced, blemishes will fade, skin will tighten, and more.
Treatment can be rendered in any area that needs a regenerative touch, but it is mostly performed on the face, neck, and chest. It is also commonly injected in the head to stimulate hair growth.
PRP injections in areas such as the face are very similar to filler injections. The process is meant to replenish moisture, volume, and nutrients that have been lost in the skin, and whose loss results in sagging, wrinkling, and an appearance of aging. PRP injections are wonderful for anti-aging, adding volume to areas with loss, plumping, smoothing, and much more.
PRP for hair loss has also proven to be quite successful and have overall rejuvenating effects on the scalp and boosting effects on existing hair follicles, but it is important to note that hair loss as an underlying physical condition will still cause hair to fall out at natural rates despite this treatment. Therefore, multiple treatments will be necessary for maintenance purposes. PRP hair restoration is thought to stimulate and strengthen existing hair follicles, but it does not create new hair follicles or restore follicles that have already died. PRP treatment can correct hair thinning, but it cannot treat complete baldness.
MICRONEEDLING PROCEDURE
Microneedling is an organic process and CIT (collagen induction therapy) that effectively takes advantage of the fortifying power of the skin’s natural ability to repair itself after suffering physical damage. Immediately after any injury to the skin, our body begins the healing process which in turn triggers synthesis of new skin cells, new collagen, and new elastin. Microneedling is able to render considerable improvement to skin texture and tone, diminish fine lines and wrinkles, soften scarring, reduce large pores, and more.
RF Microneedling is a CIT similar to regular Microneedling, but it includes an invaluable booster that imparts additional benefits to the skin. The addition of radiofrequency heat energy to the classic procedure amplifies collagen and elastin production for more defined results and increased cell turnover.
Microneedling treatment creates superficial micro-injuries, cuts, and slits in the outermost layer of the dermis to induce the body’s healing process, which includes production of new collagen and elastin. This is accomplished through 2-3 passes of consistent insertion of multiple fine needles into the skin that penetrate the dermis at controlled depths. As the skin heals, skin will tighten, and blemishes will fade away. Microneedling is performed in a safe and controlled manner with the use of a sterile, disposable needle head on a pen-like device that allows effective treatment for hard-to-reach places (e.g. around the eyes, nose, and lips). Prior to the procedure, topical anesthetic cream will be applied to the treatment area. After about 4 weeks results will be visible.
Treatment can be rendered in any area that needs a skin texture booster, but it is mostly performed on the full face, neck, and chest. RF Microneedling also does a wonderful job clearing away stretch marks and deeper scarring, which can be anywhere on the body.
Immediately after treatment, depending on the number of needles used, your skin will either be a glowy red with mild swelling, or exhibit pinpoint bleeding, redness, and irritation. Treated areas will feel tight, and sensitive to the touch. Redness and other irritation will diminish significantly within hours of treatment, but sensitivity as a result open wounding in the dermis will last for a number of days (you will feel it most when you wash your face). Please follow post-treatment instructions thoroughly.
WHAT TO EXPECT FROM TREATMENT
The treatment process in the office takes about one full hour whether clients opt to go the injection or microneedling route. Prior to the procedure, topical anesthetic cream will be applied to the treatment area. While numbing, blood will be drawn and centrifuged. Once the PRP material is prepared, the skin will either be microneedled and the PRP infused into the open channels created in the skin, or the PRP will be pulled into a syringe and injected where desired.
WHAT RESULTS TO EXPECT
Results are generally visible after 4 weeks and continue to improve gradually over the next 3‐6 months, marked by incremental improvement in skin texture and tone. Advanced wrinkling cannot be reversed and only a minimal improvement is predictable in persons with drug, alcohol, and tobacco usage. Severe scarring may not respond. End results depend on many factors, including the aggressiveness of the treatment, adherence to post-treatment instructions, proper nutrition, good general health, the degree of cumulative sun and environmental damage to the skin, and more. Of course, all individuals are different so there will be variations in results from one person to the next.
After the healing process, and after your skin has had an opportunity to synthesize collagen and elastin, you will be left with a clearer skin texture and complexion, smoothed fine lines and wrinkles, diminished scarring, reduced pores, and more. However, when PRP is used synergistically with other skin rejuvenation treatments such as fillers, lasers, peels, and more, results will be amplified. Any successful skin rejuvenation treatment is cumulative in the overall improvement of ski health, and therefore the skin’s appearance. Finally, good general health is the key to excellent and predictable outcomes, by supporting cell-health and promoting healing.
HOW MANY SESSIONS ARE NEEDED
Generally, 2‐3 treatments are advised at intervals of about 4 weeks between treatments, however more may be indicated for certain individuals. Touch-up treatments may be done bi-annually or once a year after the initial group of treatments to boost and maintain results. I understand that several appointments may be necessary to complete treatment and obtain my desired outcome. Treatments are designed to maximize results within safe and predictable parameters, but the number of treatments cannot always be accurately predicted, even under the best of circumstances. The deeper the textural or other issues with the skin, the more sessions will be needed to smooth everything out. Further, as long as underlying physical conditions that caused textural issues still exist (such as being prone to acne), regular follow-up treatment may be necessary to maintain results.
ALTERNATIVES
Alternative treatments include other noninvasive treatments such as skin peels, laser resurfacing facials, and exfoliating facials such as microdermabrasion; aggressive skincare regimens; as well as no treatment at all.
PHOTOGRAPHY RELEASE
As part of your treatment, we might be photographing and/or filming the treatment proceedings. This will allow us to visually monitor your individual progress and see the results of your treatment over time. With this form I authorize and give my full consent to sharing my outcomes and results within Lavande staff for training purposes, as educational material, and for other in-office purposes. In all cases confidentiality will be maintained to the highest degree, your identity will be kept anonymous, and the use of these materials will be strictly internal. In no way will these images be used for marketing purposes or spread to providers outside of Lavande Spa.
ACKNOWLEDGEMENTS
I am undergoing treatment voluntarily and of my own free will. I agree that this is an elective procedure being performed for cosmetic purposes and that no guarantee can be made as to the exact results of this procedure. I understand that the practice of cosmetic medicine is not an exact science and that no guarantees, warranties, or assurances can be or have been made or implied concerning the expected results in my case.
I understand that while every precaution will be taken to prevent complications and that while complications from this procedure are rare, they can and sometimes do occur. Even though appropriate measures are taken to reduce side effects, I understand that this treatment involves risks and complications that cannot be completely eliminated in every case. Complications may arise from known or unknown causes, and I freely assume those risks. I accept the risks and complications that may occur and absolve Lavande Spa and any associated persons of any blame resulting therefrom. I agree to adhere to all safety precautions and instruction post-treatment to aid in minimizing the possibility of such complications. I understand alternatives exist such as laser facials, resurfacing treatments, peeling, etc., but I elect to proceed with this treatment regardless.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand all the information contained herein, and I am aware that I will have sufficient opportunity for discussion to have any questions answered. I understand that the terms of payment require full settlement on or before the day of my treatment. I am personally responsible for payment of all services rendered to me. I understand and acknowledge that payments for the above procedure are non-refundable. Any expenses which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to dissatisfaction of my treatment outcome will be my sole financial responsibility.
By signing below, I acknowledge and certify that I have read the foregoing informed consent, fully understand the contents, and agree to treatment of Platelet Rich Plasma aka PRP Therapy via microneedling or injections techniques for the purpose of aesthetic enhancement and skin rejuvenation, and authorize Lavande aesthetic providers to perform such. I consent to this and all subsequent treatments, as well as the terms of this agreement. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees. I agree that if should I have any questions or concerns regarding my treatment/ results I will notify this office immediately so that timely follow‐up and intervention can be provided.
Name:
Signature:
Date:
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PRP Post-Op
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Please be sure to follow these conditions after your treatment:
- DO NOT take anti-inflammatory medication after the injections, as they interfere with the healing process (this includes Aspirin)
- You may take Tylenol (acetaminophen) as it is not anti-inflammatory
- No ice or heat for about 5 days post treatment
- There may be stiffness, pain, mild swelling, or redness for about 1-3 days
- Drink plenty of water, because it decreases pain and improves overall cell function
- You may return to normal activities immediately after treatment
Results will begin to show after about 3-4 weeks, but healing that yields results is a very gradual process and results can continuously show more and more for about 3-6 months after treatment.
PRP treatments are known to build on top of each other, so single treatments won’t yield the same results as multiple treatments. The usual recommended amount of treatment is 3 sessions, as patients have seen the most optimum results with this amount. One treatment may be able to reduce pore size, but it might take 3 treatments to eliminate scarring. Treatment should be spaced 1-2 months apart.
If you have any concerns, please don’t hesitate to call us at (760) LAVANDE