Templates · Free template · Regenerative consent

PRP Treatment Consent Form Template

A printable consent form for platelet-rich plasma treatments, covering the blood draw, how PRP is used, the risks, and the honest expectation that results build across a series.

Jump to the template ↓

Last reviewed September 2026 · Not legal advice

Two procedures, one consent

PRP involves a blood draw and then an injection or microneedling. The form needs to cover both: the risks of venepuncture, such as bruising and fainting, and the risks of the treatment itself.

Be candid about results. PRP is usually delivered as a series with gradual and variable outcomes, and the form should not imply otherwise.

Clinic name · address · phone

PRP Treatment Consent Form

Client

Full name

Date of birth

Phone

Screening

Blood disorder, low platelets, or on blood thinners? Yes NoIf yes, details

Active infection or skin condition in the area? Yes No

Pregnant or breastfeeding? Yes No

Faint easily with blood draws? Yes No

NSAIDs or aspirin in the past week? Yes No

Risks and acknowledgements

Initial each item to confirm you have read and understood it.

InitialsI understand my own blood will be drawn and processed to prepare PRP.

InitialsI understand risks include bruising, pain, swelling, infection, and fainting.

InitialsI understand results vary and usually require a series of sessions.

InitialsI understand PRP is prepared from my own blood, and I have disclosed all relevant history.

InitialsI agree to follow the aftercare instructions.

Consent

I have had the chance to ask questions
I received aftercare instructions
I consent to treatment

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/prp-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for med spas.

Frequently asked questions

Why is a PRP consent different from other injectables?

It covers the blood draw and processing, in addition to the treatment and its risks.

What should be said about results?

That they vary and build gradually. Avoid guarantees.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.