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PRF
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U&I Spa Inc
PRF
130 West 57th Street, Suite 14A
New York, NY, 10019
Phone: 917.214.9910
Email: uandispa@gmail.com
Please answer all questions below and press the [SUBMIT] button on all forms.
1. PERSONAL INFORMATION
*Name
*Address
Street Name, #, City, State, ZIP
*Birthdate
*Phone Number
*Emergency Contact Phone Number
*Email
How did you hear about us?
2. GENERAL INFORMATION ABOUT PROCEDURE
Platelet Rich Fibrin Therapy is an injection treatment whereby a person’s own blood is used. The full
procedure takes approximately 30 minutes. Generally, 2-3 treatments are advised, however, more may
be necessary for some individuals. Touch up treatments may be done once a year after the initial
group of treatments to boost and maintain your results.
Benefits of PRF: PRf has been shown to have overall rejuvenating effects on your skin which may
include increased collagen production, improvement in skin volume and elasticity, improvement in
hyperpigmentation, texture and tone as well as a reduction and scarring and maintenance of a youthful
appearance and glow. It is believed that PRF is helpful in over 85% of patients. Other benefits include
minimal down time, minimal risk, short recovery time, natural looking results, no general anesthesia
is required.
Risk & Complications (Less than 5%) Some of the potential side effects of PRF include: 1) Bruising
2) Infection 3) Short lasting pinkness/redness 4) swelling in the face and forehead 5) nerve irritation
or damage.
Contraindications:(Less than 1%) PRF used for aesthetic procedures is safe for most individuals
between the ages of 18-80. There are very few contraindications, however, certain diseases and/or
medications may prohibit the use of PRF. Please make sure you fill out the medical history form
completely.
Alternatives to PRF include but are not limited to micro-needling, dermal filler, PDO threads, and
Botox for prevention of fine lines and wrinkles.
Results: You will see improvement over 4-6 months after treatment. In some patients’ results may
happen sooner or take longer. The number of treatments needed depends on each individual client, the
desired outcome, and treatment plan.
3. HEALTH
*Do you have any of the following?
*Keloid/Hypertrophic Disease
.
Yes
.
No
*Active Infection (viral, bacterial, fungal)
.
Yes
.
No
*Blood Thinner Medications
.
Yes
.
No
*Recent Chemical Peel
.
Yes
.
No
*Active Acne
.
Yes
.
No
*Hormone Replacement
.
Yes
.
No
*Chemotherapy or Radiation
.
Yes
.
No
*Scleroderma
.
Yes
.
No
*Sunburn
.
Yes
.
No
*Uncontrolled Diabetes
.
Yes
.
No
*Collagen Vascular Disease
.
Yes
.
No
*Eczema, Psoriasis, Dermatitis
.
Yes
.
No
*Raised Lesions or Moles
.
Yes
.
No
*Hemophilia/Blood Disorder
.
Yes
.
No
*Cardiac Irregularities
.
Yes
.
No
*Recent Use of Topical Rx
.
Yes
.
No
*Rosacea
.
Yes
.
No
*Skin Cancer
.
Yes
.
No
*Tattoos
.
Yes
.
No
*Vascular Lesions
.
Yes
.
No
*Pregnant or Lactating
.
Yes
.
No
*Develop Cold Sores or Blisters
.
Yes
.
No
*Regular menstrual periods
.
Yes
.
No
.
N/A
*Permanent Makeup
.
Yes - Lips
.
Yes - Microblading
.
Yes - Eyeliner
.
Yes - One or more areas
.
No
*Active dermatitis, eczema or psoriasis
.
Yes
.
No
*Recent Facial Surgery (within the past 30 days)
.
Yes
.
No
*Dermal Filler or Botox (within the past 30 days)
.
Yes
.
No
*Do you have any current or chronic illnesses we should know about? Please list below:
*Drink alcoholic beverages?
.
Yes
.
No
*If yes, how often do drink you alcohol? (__ times per day/week/month)
*Consume caffeinated beverages?
.
Yes
.
No
*If yes, how often do you drink caffeinated beverages? (__ times per day/week/month)
*Exercise?
.
Yes
.
No
*If yes, how often do you exercise? (__ times per day/week/month)
*How many cups of water do you drink per day?
*What is your stress level? (1, None – 10, High): _____
4. SKIN CARE HISTORY
Please list skin concerns: (wrinkles, acne, rosacea, etc.)
Please list current medications taken, skin care products, brands and routine: (moisturizers, cleansers, serums, masks, etc.)
*Do you use Retinol (Retin-A)?
.
Yes
.
No
*If yes, date of last application:
*Select skin type/s:
.
Normal
.
Dry
.
Oily
.
Combination
.
Sensitive
.
Mature
.
Acne Prone
.
Sun Damaged
*When you go out in the sun, do you:
.
Always Burn
.
Usually Burn
.
Sometimes Burn
.
Rarely Burns
.
Never Burns
*How do you rate the overall quality of your skin?
.
Poor
.
Fair
.
Good
.
Very Good
.
Excellent
*Have you ever had a facial before?
.
Yes
.
No
*If yes, when was your last facial?
What other improvements would you like to see with your skin? (Optional)
Is there anything else we should know about you? (Optional)
5. CLIENT SIGNATURE
Consent: My consent and authorization for this elective procedure is strictly voluntary. By signing
this informed consent form, I hereby grant authority to Registered Nurse Fanuza Gareeva to perform
PRF injections and microneedling to area(s) discussed during our consultation that are listed here.
I have read this informed consent and hereby certify that I understand its contents in full. I understand
that medicine is not an exact science and acknowledge that no guarantee has been given or implied by
anyone as to the results that may be obtained by this treatment. I also understand this procedure is
“elective” and not covered by insurance and that payment is my responsibility. Payment in full for all
treatments is required at the time of service and is non-refundable.
The client indicated below also agrees to forever hold harmless and release from any and all
liability, claims, or demands of any kind or nature related to the transmission of any disease,
condition or illness including but not limited to COVID-19 they may allege to have
contracted or been exposed to as the result of any treatment, person, or visit to U&I Spa Inc.
*Client's Signature
*Date
Parent/Guardian Signature
Required if client is under 18
Date
Submit
