|
PRP/PRF Microneedling
|
|
|
Accutane past 6 months?
|
Have you used Tretinoin (Retin –A, Renova) within the last 2 weeks
|
|
Active Acne/Open Lesions
|
Recent Sun Exposure?
|
|
Do you have permanent makeup or implants?
|
Autoimmune Disorder (Lupus, Vitiligo, Scleroderma)?
|
|
Do you have have history or active Herpes I or II – in the areas to be treated
|
History of immunosuppression?
|
|
Corticoid steroid use in past 2 weeks?
|
History Chronic Liver disease?
|
|
Cancer/Chemotherapy within past year?
|
Dermal Fillers or Botox within past 10 days?
|
|
Scars <6 months old to area to be treated?
|
History of Acne?
|
|
History of eczema, rosacea, or psoriasis?
|
Have you had Laser Resurfacing within the last 6 months?
|
|
Have you had a Chemical Peel – within the last 4 weeks
|
History of blood disorders?
|
|
Risks/Benefits Reviewed and questions answered
|
|
|
|
|
|
Amount of blood drawn
|
Blood Draw Site
|
|
Blood Draw Needle
|
Blood Draw Attempts
|
|
Amount of PRP used
|
|
|
Maximum Depth of Microneedling Used
|
Area(s) Treated
• • •
|
|
Passes
|
Other:
|
|
Performed By
|
Post Care Instructions
• • •
|
|
|
|
|
PRP/PRF Injections
|
|
|
Do you have have history or active Herpes I or II – in the areas to be treated
|
Corticoid steroid use in past 2 weeks?
|
|
History of blood disorders?
|
Dermal Fillers or Botox within past 10 days?
|
|
History of immunosuppression?
|
Risks/Benefits Reviewed and questions answered
|
|
mL of blood drawn
|
Blood Draw Site
|
|
Blood Draw Needle
|
Blood Draw Attempts
|
|
Amount of PRP used
|
Area(s) Treated
• • •
|
|
Anesthetic used
|
Needle
• • •
|
|
Other:
|
|
|
Post procedure bruising
|
Performed By
|
|
Additional Notes:
|
|
|
Before Photo
|
Before Photo
|
|
|
|
|
PRP/PRF Hair Restoration
|
|
|
History of blood disorders?
|
History of immunosuppression?
|
|
Corticoid steroid use in past 2 weeks?
|
Risks/Benefits Reviewed and questions answered
|
|
Amount of blood drawn
|
Blood Draw Site
|
|
Blood Draw Needle
|
Blood Draw Attempts
|
|
Amount of PRP used
|
Needle
• • •
|
|
Anesthetic Used
• • •
|
|
|
Anesthetic used
|
Nerve Block Location
• • •
|
|
Performed By
|
Additional Notes:
|
|
Post Care
• • •
|
|
|
Before Photo
|
Before Photo
|
|
Before Photo
|
Before Photo
|
