I hereby authorize Microinjections of my plasma from the blood extracted to me and being centrifuged into my (body area)

I understand that an average of 6 – 8 treatments are required for PLATELET RICH PLASMA to be most effective; other treatments may then be necessary over the years to maintain the result. I realize that everyone’s treatment response may be different; therefore, the number of treatments necessary to achieve the desired result may vary. I understand that it is important to follow the recommended schedule for the future treatment to obtain the best result. I understand that there has been no warranty, assurance, or guarantee of successful treatment made for me.

I have been informed of the risks and side–effects. Bruising, irritation, bleeding at the site, and small hematoma might occur after each session. They are, however, transitory. Rare but reported risks include infection and allergic reaction manifested as redness, swelling, and high discomfort in the injected sites.

I may terminate at any time. I have had the chance to ask questions, and answers have been given. I understand that the physician may choose to take before – and – after photographs of my treatment area(s) for monitoring my progress as well as for promotional and educational purposes.