By signing the bottom of this page I hereby acknowledge the following:

1. That I have discussed the nature of my condition, the contemplated procedure (PRP), the general nature of the proposed treatment, and the circumstances and basis upon which I have made a request for the proposed treatment.
2. That the nature of the procedure itself has been explained to me as well as alternative methods available and any disadvantages and advantages of one method over another.
3. That the prospects for success and likely benefits of such treatment have been fully discussed with me to my satisfaction.
4. That the possible risks of this treatment have been thoroughly discussed with me to my satisfaction, and that I have been told that the possible risks of this treatment include but are not limited to minimal results, infection, the need for possible further treatment and swelling.
5. That I have been advised that there may be other particular risks associated with the procedure because of my medical condition(s)
6. That although good results are expected, the possibility and nature of complications cannot be definitively stated and that, therefore, there can be no guarantee either as to the success or otherwise of the treatment.
7. That the results are not permanent as degradation of the collagen tissue will occur over time.
8. That I have been given an opportunity to ask any questions that I have and that my questions have been answered in a full and satisfactory manner.
9. That I have had the opportunity to seek medical advice from my general practitioner if I want to before deciding to proceed with this procedure.
10. That before signing this document any blanks on this page where details are to be inserted regarding risks and any named physician and/or associate or assistant have been completed.
11. That before signing this document I have read it (or it has been read to me) and that I understand the information contained in this document and the nature of the acknowledgements and consent I am giving.
12. That the information collected in this form is necessary information to ensure I receive the most appropriate procedure and that all risks are avoided as far as possible.