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Revesby
Westfield Eastgardens
Clemton Park
Rouse Hill

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Revesby
Westfield Eastgardens
Clemton Park
Rouse Hill

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PRP

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Clemton Park Revesby Rouse Hill Eastgardens

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Address *

Mobile *

D.O.B *

Occupation *

Procedure 1

Date

Procedure 2

Date

Procedure 3

Date

Procedure 4

Date

Have you been diagnosed with one or more of the following?

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High blood pressure

Chronic Liver Pathology

Heart disease

Are you pregnant or breast feeding Diabetes

Taking steroids or aspirin Respiratory problems

Anti-Coagulation Therapy

Bowel problems

Drug dependency / alcohol abuse Epilepsy

Mental illness / depression

Allergies or anaphylactic (severe) reactions Severe Metabolic

Facial Herpes Simplex

Systemic Disorders

Platelet Dysfunction Syndrome

Skin Disease, Skin Cancer or Facial Herpes

Critical Thrombocytopenia

Haemodynamic Instability

Hypoﬁbrinogenemia

Sepsis

Acute and Chronic Infections

Anaemia

Taking any other kind of medication: If yes, please specify: *

Other conditions not mentioned: If yes, please specify: *

Consent * I, hereby authorise and consent to the named physician and/or associate or assistant of his/her choice performing the application of the PRP.

Patient Details

First Name *

Last Name *

Email Address *

Date of Consent *

Client Signature *

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