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Consent Form for Hair Loss Treatment with PRP, ACell, and Minoxidil

Prime HealthAddress: 1035 Sterling Rd, Suite 104, Herndon, VA 20170

Physician Name: Dr. Han Tonthat

1. Purpose of This Consent

By signing this form, I confirm that I have been informed about the hair loss treatments utilizing Platelet-Rich Plasma (PRP), ACell therapy, and Minoxidil. I understand the nature, purpose, potential benefits, and risks of these treatments and voluntarily consent to proceed.

2. Description of Treatments

Platelet-Rich Plasma (PRP):

PRP involves drawing a small amount of my blood, processing it to concentrate platelets, and injecting it into the scalp to stimulate hair follicles and improve hair growth.

ACell Therapy:

ACell is a regenerative medicine treatment that uses extracellular matrix (ECM) proteins to support tissue healing and repair, injected alongside PRP to enhance scalp rejuvenation and follicle health.

Minoxidil:

Minoxidil is a topical medication applied to the scalp to improve blood flow and stimulate hair follicles, encouraging hair regrowth and preventing further hair loss.

3. Expected Benefits

These treatments aim to:

  1. Stimulate natural hair growth by enhancing blood flow and revitalizing dormant hair follicles.

  2. Strengthen existing hair and slow the progression of hair loss.

  3. Support long-term hair health through regenerative therapy.

4.Common Side Effects (Temporary and Mild)

Platelet-Rich Plasma (PRP) Side Effects

Common Side Effects (Temporary and Mild):

  1. Redness and Swelling: Mild redness or swelling at the injection sites, typically resolving within 24–48 hours.

  2. Tenderness or Pain: Discomfort in the treated areas, lasting a few days.

  3. Bruising: Minor bruising from needle punctures, which may take up to a week to fade.

  4. Itching or Tingling: Sensations due to increased blood flow or healing in the scalp.

  5. Scalp Tightness: A feeling of tightness or sensitivity in the treated areas.

Less Common Side Effects:

  1. Prolonged Redness or Swelling: Inflammation that lasts longer than expected.

  2. Localized Scalp Irritation: Mild irritation or flaking due to the injection process.

  3. Temporary Shedding: Increased hair shedding due to the stimulation of hair follicles entering a new growth phase.

Rare but Serious Risks:

  1. Infection: Bacterial or fungal infection at the injection site.

  2. Allergic Reaction: Rare sensitivity to local anesthetics (if used) or the PRP preparation process.

  3. Nerve or Blood Vessel Injury: Rare instances of unintended trauma during injection.

ACell Therapy Side Effects

Common Side Effects (Temporary and Mild):

  1. Redness and Warmth: Mild warmth or redness in the treated area.

  2. Tenderness or Soreness: Temporary discomfort in the scalp after injections.

  3. Minor Swelling: Short-term swelling that subsides within a few days.

Less Common Side Effects:

  1. Prolonged Swelling or Pain: Localized discomfort lasting beyond 48 hours.

  2. Scalp Sensitivity: Increased sensitivity to touch or scalp products.

Rare but Serious Risks:

  1. Infection: Potential bacterial contamination at injection sites.

  2. Allergic Reaction: Uncommon but possible sensitivity to the ACell material.

  3. Granuloma Formation: Formation of small lumps under the skin due to an immune response to the injected material.

Minoxidil Side Effects

Common Side Effects (Temporary and Mild):

  1. Scalp Irritation: Dryness, redness, or itching at the application site.

  2. Flaking or Peeling: Due to prolonged use or sensitivity to the product.

  3. Temporary Shedding: Increased hair loss initially as weaker hairs shed to make way for new growth.

Less Common Side Effects:

  1. Unwanted Hair Growth: Hair growth on areas outside the scalp (e.g., forehead, face, or body) if the product drips or spreads.

  2. Dizziness or Lightheadedness: Rare, but possible in sensitive individuals.

  3. Scalp Sensitivity: Increased sensitivity to touch or other hair products.

Rare but Serious Risks:

  1. Allergic Reaction: Symptoms include rash, swelling, or hives.

  2. Systemic Absorption Issues:

    • Low blood pressure.

    • Rapid or irregular heartbeat.

    • Swelling of the hands or feet (edema).

Combination Treatment Side Effects

Using PRP, ACell, and Minoxidil together may result in:

  1. Amplified Scalp Irritation: Increased redness, dryness, or sensitivity due to overlapping treatments.

  2. Prolonged Healing: Delayed resolution of redness or swelling when multiple modalities are combined.

  3. Temporary Hair Thinning: Due to synchronized shedding cycles from the combined stimulation of hair follicles.

  4. Infection Risk: Increased risk if proper hygiene is not maintained across all treatments.

Long-Term Risks

Rarely, the following long-term side effects may occur:

  1. Scarring: Permanent marks or texture changes at injection sites, typically due to improper healing or infection.

  2. Pigmentation Changes: Hyperpigmentation or hypopigmentation in the treated areas.

  3. Resistance to Treatment: Reduced efficacy of Minoxidil with prolonged use due to tolerance.

  4. Persistent Shedding: In some individuals, shedding may not stabilize.

Key Points for Patients

  1. Most side effects are mild and temporary, resolving on their own within a few days to weeks.

  2. Serious complications are rare, but immediate medical attention is necessary for symptoms such as severe swelling, infection, or allergic reactions.

  3. Proper adherence to pre- and post-treatment instructions significantly reduces the likelihood of side effects.

5. Contraindications

I confirm that I do not have any of the following conditions or factors that may increase risks:

  • Active scalp infections, rashes, or open wounds.

  • Blood disorders or bleeding conditions.

  • Pregnancy or breastfeeding.

  • Allergies to Minoxidil or materials used in PRP or ACell therapy.

  • Current use of medications that may interfere with blood clotting (e.g., anticoagulants).

6. Pre-Treatment and Post-Treatment Instructions

To ensure optimal results and minimize risks, I agree to follow these instructions:

Pre-Treatment:

  1. Avoid alcohol, smoking, and blood-thinning medications for 48 hours before PRP/ACell treatment.

  2. Wash and dry the scalp thoroughly before the procedure.

  3. Notify the Clinic of any changes in medical history or medications.

Post-Treatment:

  1. Avoid touching or washing the scalp for 24 hours after treatment.

  2. Use gentle, recommended products on the scalp for cleaning and moisturizing.

  3. Avoid sun exposure, saunas, and strenuous activity for 48 hours.

  4. Use Minoxidil as directed by the practitioner.

  5. Refrain from using harsh hair treatments or dyes for 7 days.

Failure to follow post-treatment care instructions may result in complications or suboptimal results.

7. No Guarantee of Results

I understand that aesthetic outcomes are subjective and may vary. While the procedure is performed with care, Prime Health cannot guarantee specific results, and touch-ups may be necessary for optimal results.

8. Refund Policy

The Patient acknowledges and agrees to the following refund terms:

  1. Non-Refundable Services: All fees for completed services are non-refundable.

  2. Health-Related Refunds: If treatments are stopped due to verified health issues, refunds will be issued only for unused treatments.

  3. Payment Obligations: If enrolled in a payment plan, the Patient must complete all payments, even if they discontinue the program.

9. Emergency Contact


9. Acknowledgment and Consent

By signing below, I confirm that:

  1. I have read and understood this Consent Form and its contents.

  2. I have been informed of the procedure, risks, and benefits, and had all my questions answered.

  3. I understand the risks, including rare but serious complications, and agree to proceed with the treatment.

  4. I release Prime Health, its staff, and practitioners from liability for any complications, except those caused by gross negligence or malpractice.

Date
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