CABINET TESLA  —  MEDICAL IMAGING CENTER

Cognac Clinic  •  Dr Pierrick MORALES

Consent — PRP Infiltration
71, Avenue d'Angoulème – 16100 Chateaubernard – COGNAC
Tel. : 05.45.35.68.91  •  Fax : 05.45.82.56.40  •  secretaire@radiologie-cognac.com
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ℹ️ Information about your infiltration — please read carefully ▼

Your doctor has proposed a PRP infiltration. It will be performed with your consent.
You are free to accept or refuse it.
To help you decide, please read the information provided below carefully.

What does the procedure involve?

PRP infiltration consists of injecting a platelet-rich plasma concentrate into a tendon, peri-tendinous, muscular or intra-articular injury to promote healing.

Why is this procedure performed in the Radiology department?

The procedure will be performed under ultrasound or fluoroscopic guidance to select the best needle entry point and track its path.

How the procedure is performed:

The procedure is performed lying down. First, a blood sample is taken in a sterile tube. This tube is centrifuged to separate the different blood components: red blood cells and platelets.
After platelet extraction and preparation of sterile equipment, strict skin disinfection is performed; under ultrasound guidance, the radiologist then injects the PRP using a needle under optimal aseptic conditions.

What are the benefits and limitations of the infiltration?

This infiltration aims to promote tendon healing and thereby reduce pain and functional impairment, but results are not guaranteed.

What are the risks of the infiltration?

Any intervention on the human body, even when performed under maximum conditions of skill and safety, carries a risk of complications.
Because PRP is derived directly from your own body, very few side effects are expected. In some cases, however, the following may occur:

If you experience pain after the procedure, pain relievers (analgesics) are permitted; however, anti-inflammatory drugs must be avoided for 10 days.

Results

Lying down and resting on the day of the injection and, if possible, the following day is advised for better results. Improvement can take a while to appear, in the order of 2 to 3 months.
If physiotherapy is ongoing, it should be resumed 15 days after the injection — please inform your physiotherapist.

After returning home:

Limit joint movements for 24 to 48 hours to avoid pain or effusion.

If you have persistent pain or any unusual symptoms (fever, chills, dizziness…), contact your GP or the radiologist on 05 45 82 08 80.

It is natural to have questions about the procedure. We hope we have answered them. Please feel free to ask us for any further information.

📋 Patient information

* Required: at least one 10-digit phone number and a valid email address.

⚠️ Please read each question carefully and correct if needed.

🩸 Bleeding risks
1
Do you have a blood disorder or frequent/prolonged bleeding?
2
Are you taking an anticoagulant or antiplatelet medication?
Aspirin, Plavix, Warfarin, Rivaroxaban, Apixaban…
⚠️ If yes, it will be necessary to stop these medications before the injection (the physician will specify for how long).
💊 Anti-inflammatory drugs
3
Are you currently taking anti-inflammatory medications?
Ibuprofen, Ketoprofen, Diclofenac, Naproxen, Celecoxib…
⚠️ You are advised to stop them 2 days before the infiltration and not to restart them for 10 days afterwards.
As a general rule, please do not hesitate to provide any information you feel is important, and to tell us about any serious illness.
📋 What you need to do
Bring with you on the day of the infiltration:
For the infiltration: there is no need to fast. Please come with someone if you can.
After the procedure, the treated area may be painful — consider using a support device if needed (splint, sling for the elbow/shoulder, crutches for the knee/foot/ankle).
After returning home: rest is advised; limit movement of the joint for 24 to 48 hours. The effect of the infiltration will only become noticeable after a few days.
💶 Fees (not covered by French state health insurance)
1st PRP 150 €not covered by insurance
2nd PRP 100 €not covered by insurance
3rd PRP 100 €not covered by insurance
✍️ Patient consent

I, the undersigned, Mrs / Miss / Mr (delete as appropriate), certify that I have personally completed this form, that I have read and understood the information above, and I consent to the infiltration being performed. — NB: to be completed by a parent or guardian for minors.

Signature :

Sign in the box above