PRP Eye drops for when it seems you've tried everything

Patient Registration | Questionaire | Consent

OCULAR HISTORY

Please complete the following information so we can learn more about your dry eye problem. We never sell your information.

Informed Consent

INTRODUCTION

This information is being provided to you so that you can make an informed decision about PLATELET RICH PLASMA (PRP). The

process involves withdrawing your blood and processing it to separate out the different blood components to isolate the platelet-concentrated portion of the plasma. The PRP is custom compounded into therapeutic eye drops FOR YOUR USE ONLY.

BENEFITS of PRP

PRP is autologous (using your own blood) therefore eliminating allergy potential. PRP has been shown to have tissue regenerating

effects and has been been shown to heal the ocular surface (cornea and conjunctiva) as well as tear production glands of the eye.

PRP's safety has been established for over 20 years for its wound healing properties and its theoretical effectiveness has extended

across multiple medical specialties. Safety is further enhanced as no other medications or chemicals are added to reduce the

possibility of side effects.

CONTRAINDICATIONS TO TREATMENT

PRP use is safe for most individuals between the ages of 18 and older. There are very few contraindications, however, patients with

the following conditions are not candidates: 1. Pregnancy or Lactation 2. Acute and Chronic Infections 3. Skin diseases (i.e. SLE,

porphyria, allergies) 4. Cancer and/or Chemotherapy treatments 5. Severe metabolic and systemic disorders 6. Abnormal platelet

function (blood disorders, i.e. Hemodynamic Instability, Hypofibrinogenemia, Critical Thrombocytopenia) 7. Chronic Liver Disease

8. Anti-coagulation therapy (Coumadin, Warfarin, Plavix, Aspirin, Lovenox) 9. Underlying Sepsis

ALTERNATIVES to TREATMENT

There are alternatives to this treatment: 1) You can simply do nothing 2) You can try other lubricant and medicated eye drops 3)

hot compresses and other eyelid hygiene measures improve the eyelid meibomian gland oil secretions.

RISKS of TREATMENT

PLATELET RICH PLASMA is an elective procedure to treat chronically dry & irritated ocular surfaces. There is no emergency condition

or other reason that requires or demands that you have it performed.

This procedure, like all medical intevention, presents some risks, many of which are listed below:

1. Pain, bleeding, and/or bruising at the blood draw site

2. Irritation from the eyedrops (very unlikely)

3. Minimal or no eect from the treatment

PATIENT CONSENT

In giving my permission for blood withdrawal and PRP processing. I understand the following: The provider will use a needle to

obtain blood. That blood will be processed to isolate and then concentrate the platelets in the plasma portion of the blood. No

other medications will be added. The PRP uid will be custom compounded into therapeutic eye drops for the patient.

PATIENT’S STATEMENT OF ACCEPTANCE AND UNDERSTANDING

The details of the procedure known as PLATELET RICH PLASMA have been presented to me in detail in this document. The amount of drops should supply about 3-4 months of treatment (if one eye) and 2-3 months if both eyes. They will be supplied in multiple small (5ml) dropper bottles

that should be refrigerated (or frozen) when not used. I understand that because they are a biological product and are made from the patient,

THEY ARE NOT TO BE SHARED OR USED BY OTHER PERSONS. Since the above information does not change, if I return for another

treatment/PRP processing, this consent will apply to any subsequent visits.