Platelet Rich Plasma PRP Consent Form

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Arbitration Agreement *

ARBITRATION AGREEMENT This Agreement is made on date of signature stamp, between Blue Aesthetics Inc, DBA 'Hi Beautiful Aesthetics' of 9400 Westheimer Rd, hereinafter referred to as "First Party" and client named above or signing this agreement virtually, hereinafter referred to as "Second Party." WHEREAS, the business relationship between the parties commenced as dated above by client as defined in the original business contract, which is attached and incorporated herein; AND WHEREAS the parties herein recognize disputes and differences may arise between the parties; AND WHEREAS the parties recognize that litigation in court can be time consuming and expensive; AND WHEREAS the parties agree it is in their best interest to appoint an arbitrator to resolve such disputes as they arise at the cost of client; NOW IT IS AGREED BETWEEN THE PARTIES HERETO AS FOLLOWS: The parties hereto agree to refer the following matters and responsibilities to the Arbitrator and not a lawyer or a court of law: To resolve all disputes and differences under the original contract/consent form, To review the terms of the contract and determine the amount payable by one party to the other, if any To make provisions for the payment of debts and liabilities of the business including income tax liabilities In the event there are any disputes or controversies that arise between the parties pursuant to the terms of the aforesaid Contract, then the parties are waiving their right to litigate these issues in court and instead elect to have these disputes resolved through arbitration. The parties agree that any disputes are to be arbitrated through the American Arbitration Association and that the parties agree to abide by the rules of the Commercial Arbitration Rules of the American Arbitration Association. WHEREFORE, it is agreed that all claims and disputes arising or relating to the Contract are to be settled by binding arbitration in the State of Texas. Said arbitration is to be resolved through the Commercial Arbitration Rules of the American Arbitration Association and the parties agree to abide by these rules. Any decision or award as a result of any such arbitration shall be issued in writing and the arbitrator shall be mutually selected pursuant to the Commercial Arbitration Rules of the American Arbitration Association. Any arbitration award may be confirmed in a court of competent jurisdiction. This Agreement shall be signed by a representative (employee, which is kept on file) on behalf of Blue Aesthetics Inc, DBA 'Hi Beautiful Aesthetics' and by client. I understand & agree this is a legal representation of my signature.

PRP Injections *

Procedure Overview: Platelet-Rich Plasma (PRP) therapy involves drawing a small amount of your own blood, processing it to concentrate the platelets and growth factors, and injecting the PRP into the scalp to stimulate natural hair regrowth. This is a minimally invasive, regenerative procedure used to treat thinning hair and early hair loss, especially androgenic alopecia. Expected Benefits: Stimulation of dormant hair follicles Increase in hair density and thickness Improvement in scalp health and circulation Reduction in excessive shedding Non-surgical, natural method using your body’s own cells Treatment Series Recommendation: A minimum of three (3) sessions spaced approximately 4–6 weeks apart is recommended for optimal results. Maintenance sessions may be advised every 4–6 months depending on your response and goals. Combining PRP therapy with medication or exosome therapy may accelerate or enhance outcomes. Potential Risks & Side Effects: As with any injectable treatment, there are some possible side effects and risks, including but not limited to: Temporary redness, swelling, or bruising at injection sites Mild discomfort or tenderness of the scalp Headache or temporary tightness Infection at the injection site (rare) Temporary shedding or “shock loss” before regrowth (rare) No guarantee of hair regrowth or success; individual results vary Contraindications & Precautions: You should not undergo PRP treatment if you: Have active scalp infections or open wounds Have uncontrolled blood disorders (e.g., low platelet count, clotting issues) Are currently undergoing chemotherapy or radiation Are pregnant or breastfeeding Have autoimmune scalp diseases without clearance Use blood thinners (must be discussed with the provider beforehand) Client Acknowledgment & Consent: Please read and initial next to each statement: ____ I understand that PRP injections use my own blood components and carry minimal risk of allergic reaction. ____ I understand that results vary and that no specific outcome is guaranteed. ____ I understand that a series of treatments is typically required for best results. ____ I understand that follow-up appointments are crucial to monitor progress and make any needed adjustments. ____ I have disclosed all relevant medical history, medications, and conditions. ____ I consent to photographs being taken for medical record purposes. ____ I have had all of my questions answered and am satisfied with the information provided. ____ I understand that combining PRP with other treatments (such as medication or microneedling) may improve results. Consent Statement: I understand the nature, purpose, benefits, risks, and possible complications of PRP scalp injections. I have had the opportunity to ask questions and all of my concerns have been addressed. I freely consent to receive PRP therapy for hair restoration at Renovo Hair Restoration & Wellness.ption 1

I agree and have read all the consent forms and I am aware of all complications that can arise. I understand that I will notify my esthetician of any contraindications that may arise. My electronic signature will service as a binding agreement between me and Renovo Hair Restoration & Wellness

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