Informed Consent for Phlebotomy and Plasma Rich in Growth Factors Development. (PRGF)

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Patient name:(Required)

You have the right to be informed about your condition and the recommended treatment plan to be used so that you may make an informed decision as to whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to alarm you but is rather an effort to properly inform you so that you may give or withhold your consent.

Plasma Rich Growth Factors

The patient’s blood is drawn from the patient like any blood test. In order to process PRGF, there will be a 20-40 ml blood-draw using an aseptic technique. Dr. Safari will separate the plasma from your blood through a centrifuge spinning process. The blood will be processed, activated, and added to the surgical procedure. To activate PRGF, the blood is mixed with calcium chloride. To explain the benefits in further detail, Plasma is a component of your blood that contains special “growth factors,” or proteins, that help your blood to clot. It also contains proteins that support cell growth. Your isolated concentrated plasma will then be placed directly into the healing site. The use of the plasma of a concentration of a patient's own platelets will help accelerate the healing and growth using each individual patient's own healing system to promote improvement and regeneration in the area. The idea is that injecting PRP into damaged tissues will stimulate your body to grow new, healthy cells and promote healing and growth.

Summary of Benefits: Regeneration in post-extraction sites. Regeneration of bone around implants improved the Osseo-integration of implants. Faster wound healing, as well as pain reduction. Please, keep in mind that this procedure can be done without PRGF, however, the success of the regeneration of tissue is known to be greater with this process which is optimal for the healing process and success. If you choose to opt-out of this procedure, please let the front desk know immediately and sign the refusal portion below.

**I understand that the medical/dental personnel and others will rely on statements about me, my medical history, and other information in determining whether to perform the procedure or the course of treatment for my condition and in recommending the procedure, which has been explained. I understand that the practice of dentistry and medicine are not exact sciences and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.

I understand that during the course of the procedure described, it may be necessary to perform additional procedures which may not be known to be needed at the time this consent is given. I authorize the persons described herein to make decisions concerning such procedures. I also consent to and authorize the performance of such additional procedures, as may be deemed necessary or appropriate.
I understand that certain medications, drugs, anesthetics, and prescriptions may cause drowsiness and lack of awareness and coordination which may be increased by the use of alcohol or other drugs. Thus I have been advised not to drive or operate hazardous equipment or work while taking medications and/or drugs until I have fully recovered from the effects. I understand and agree that if I have been sedated or given general anesthesia, I will not operate any vehicle or hazardous device for 24 hours after my release from surgery. I agree not to drive myself home after the surgery and will have a responsible adult drive me home after being discharged from surgery. I consent to photographs, recordings, and x-rays of the procedure to be performed for the advancement of dentistry.

BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR EXPLAINED TO ME, THAT I FULLY UNDERSTAND IT’SCONSENTS, THAT I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND THAT ALL QUESTIONS HAVE BEEN ANSWERED SATISFACTORILY.CONSENT: I hereby voluntarily request and consent to the performance of the procedures described or referred to herein by Dr. Mark Safari, involved in the course of my treatment.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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****Only sign below if you refuse the PRGF process****

I hereby refuse the PRGF process and understand that my success rate of my surgical procedure may decrease because of my choice.

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