Consent for Platelet Rich Plasma (PRP)

I hereby authorize Dr. Edward S. Rubin or whomever is designated as his assistant, to perform a Platelet Rich Plasma (PRP) procedure on me.

I understand that if any unforeseen condition arises during the procedure, Dr. Rubin can use his judgment for any additional steps or changes to the procedure. I further request and authorize Dr. Edward S. Rubin to do whatever is deemed medically necessary for me.

I acknowledge that:

• •The diagnosis, nature of the treatment, and the scientific basis of the procedure has been explained to me. I have had an opportunity to ask questions concerning it, which all have been answered to my satisfaction. The related literature and scientific evidence were discussed in detail regarding the procedure.
• •I have been advised that the technique of the procedure is a recognized form of treatment for conditions such as mine.
• •The clinical examination and symptomatology were discussed in detail with me. I have failed to achieve sustained pain relief from analgesics including but not limited to physical therapy and steroid injections. At this point, I am a good candidate for platelet rich plasma (PRP).
• •There is evidence in the literature supporting the safety and effectiveness of PRP.
• •This therapy is off-label and not FDA approved, and insurance will not cover the cost of the procedure. I am responsible for paying the cost of the procedure. I was made aware that PRP is pro-inflammatory, and pain may increase for a week or two. I was advised not to take any anti-inflammatory or anti-platelet medication (e.g., Plavix) one week before and two weeks after the procedure. I will obtain approval from my primary care physician to stop such medication if needed.
• •I was made aware that the PRP injection may not provide expected results.
• •The risks, complications, and side effects were discussed in detail, including but not limited to infection, bleeding, nerve injury, or allergic reaction.
• •Along with the nature and purpose of this therapy, I have been additionally advised regarding possible alternative or conventional methods of treatment, including no treatment.
• •If I experience any adverse reaction or side effects, I was advised to call the office or go to the nearest emergency room.
• •If any unforeseen condition arises during the procedure, I further authorize my physician to do whatever is deemed medically advisable.