Practice
Navara Health, PLLC
5301 Alpha Road, Suite 34, Room 21
Dallas, Texas 75240
Contact
469-653-3124
contact@navarahealthtx.com
Treating Provider · CMA-Certified
Jessica Boggs, MSN, APRN, FNP-C, ENP-C
Medical Director
Simal Patel, MD
Service Location
Dallas, Texas (In-Clinic Only · Adults 18+)
Purpose of This Consent
I am electing to undergo Vampire Hair Restoration® — a CMA-trademarked Platelet-Rich Plasma (PRP) scalp therapy protocol — to support scalp health and hair follicle function. The procedure may include optional adjunctive components such as microneedling and topical or injectable local anesthetic.
This document explains the nature of the procedure, its components, the potential benefits, known and unknown risks, alternatives, and limitations. I have read this document carefully and have had the opportunity to ask questions before signing.
Procedure components are individualized. Not every patient will receive every component. The specific components I am consenting to today are indicated in the Procedure Components — Selection at Consent block below.
Procedure Description
Core Component
A · Platelet-Rich Plasma (PRP) Scalp Therapy
The Vampire Hair Restoration® protocol involves drawing a sample of my blood, processing it in a closed centrifuge system to concentrate the platelets and plasma-derived growth factors, and reintroducing the concentrated PRP into areas of the scalp affected by thinning or hair loss through targeted injection.
PRP may support:
- Increased localized blood flow to hair follicles
- Activation of follicular stem cells and growth factor signaling
- Prolongation of the anagen (growth) phase of the hair cycle
- Reduction of scalp inflammation
I understand that PRP does not create new hair follicles. It may improve the activity and density of existing follicles. A series of 3–6 treatments, spaced approximately 4–8 weeks apart, is commonly recommended for the initial course, with maintenance treatments every 6–12 months.
Optional Adjunct
B · Scalp Microneedling
Microneedling uses sterile single-use needles to create controlled micro-channels in the scalp to:
- Enhance PRP absorption and topical delivery
- Stimulate collagen production and growth-factor signaling
- Mechanically activate wound-healing pathways
Microneedling is optional. It may increase post-procedure redness, tenderness, pinpoint bleeding, crusting, and downtime relative to PRP injection alone.
Optional Adjunct
C · Topical & Injectable Local Anesthetic
For comfort, one or both of the following may be used:
- BLT topical anesthetic — a compounded combination of benzocaine, lidocaine, and tetracaine applied to the scalp prior to the procedure
- Injectable lidocaine, which may also be admixed into the PRP preparation in small amounts to reduce injection discomfort
Anesthetic options will be reviewed with me. I understand these add their own risks (described in Section 3).
Expected Course of Treatment
- Hair restoration is gradual; visible changes typically take 3–6 months and may take longer
- Temporary shedding ("shock loss") may occur in the early weeks as follicles transition phases — this is usually a sign of cycle activation, not damage
- Multiple sessions are typically required for visible response; a single session is not expected to produce a durable result
- Maintenance treatments every 6–12 months may be recommended to sustain effect
- Concurrent or adjunctive therapies (minoxidil, finasteride, dutasteride, low-level laser therapy, nutrition, hormone optimization) are often recommended for best results
- Clinical photographs may be used for medical documentation, and — only with separate written authorization — for marketing or education (see Photography section below)
Risks & Possible Complications
Common / Expected
Injection-Site & Procedure Effects
Redness, swelling, mild bruising. Scalp tenderness, tightness, or itching. Mild headache. Temporary shedding ("shock loss"). Pinpoint bleeding or crusting (especially with microneedling). Mild discomfort during injection. Pain or bruising at the blood draw site (arm).
Possible
Less Common Reactions
Scalp infection or folliculitis. Inflammatory flare (especially with underlying scalp condition such as seborrheic dermatitis, psoriasis, or alopecia areata). Allergic reaction to anesthetic, antiseptic, or topical product. Dizziness or vasovagal response during blood draw or injection. Swelling of the forehead or periorbital area lasting several days. Persistent injection-site nodules. Worsening of underlying hair loss condition. Reactivation of cold sores at the hairline (rare). Insufficient platelet yield for an effective preparation.
Rare but Serious
Significant Risks
Anaphylaxis or severe allergic reaction (especially to anesthetic components — see Section 4).
Local anesthetic systemic toxicity (LAST) from lidocaine — neurologic and cardiovascular symptoms (rare with the small doses used). Scarring or keloid formation. Injury to nerves or blood vessels. Prolonged numbness or altered sensation. Significant or persistent infection requiring antibiotics. Lack of response despite appropriate care. Unforeseen biologic effects — long-term human data on repeated PRP exposure is still evolving.
Risks Specific to Local Anesthetic (If Selected)
If BLT topical or injectable lidocaine is used, additional risks include:
- Temporary numbness, tingling, or unusual sensation at the application site
- Redness, irritation, or contact dermatitis from BLT
- Allergic reaction to one or more anesthetic components
- Methemoglobinemia (rare) — particularly with benzocaine in BLT, presenting as bluish discoloration, headache, fatigue, or shortness of breath
- Local anesthetic systemic toxicity (LAST) with lidocaine — central nervous system symptoms (perioral numbness, tinnitus, metallic taste, agitation, seizures) progressing to cardiovascular collapse (rare with the small volumes used in PRP admixture)
- Cardiovascular effects in patients with underlying heart disease
I will disclose any prior reaction to local anesthetics or topical products before treatment.
Contraindications & Required Disclosures
The procedure may be contraindicated or require deferral if I have or disclose:
- Active scalp infection, open wound, or untreated dermatitis
- Active or recent cancer (within the previous 12 months unless cleared by oncology)
- Hematologic malignancy or platelet dysfunction syndrome
- Bleeding or clotting disorder, or anticoagulant therapy (case-by-case review)
- Autoimmune disease affecting hair growth (alopecia areata, lupus involvement of the scalp, scarring alopecias) — may still be candidate but requires careful clinical judgment
- Significant uncontrolled medical conditions
- Pregnancy, possible pregnancy, or breastfeeding
- Isotretinoin (Accutane) use within the previous 6–12 months
- Known allergy or hypersensitivity to lidocaine, BLT components (benzocaine, lidocaine, tetracaine), latex, adhesives, antiseptics, or any product component
- History of poor wound healing or keloid formation
- Active substance use disorder
Failure to disclose accurate medical history may increase my risk of complications and limits the practice's ability to provide safe care.
Pre- and Post-Procedure Responsibilities
Before Treatment
- Disclose all medications, supplements, blood thinners, recent procedures, and any active scalp conditions
- Avoid NSAIDs (ibuprofen, naproxen, aspirin), fish oil, vitamin E, ginkgo, garlic supplements, and alcohol for 48–72 hours before (unless medically required) — these can reduce platelet effectiveness and increase bruising risk
- Eat a meal and hydrate well before the appointment (PRP requires a blood draw)
- Arrive with clean hair and scalp, free of styling products
- Notify provider of any cold sore history at the hairline (prophylactic antiviral may be recommended)
After Treatment
- Do not wash hair or wet scalp for 24 hours (4 hours minimum if absolutely necessary)
- Avoid styling products, dyes, harsh shampoos, and chemical scalp treatments for 72 hours
- Avoid strenuous exercise, saunas, hot tubs, and excessive heat exposure for 24–48 hours
- Avoid alcohol for at least 24 hours
- Avoid blood thinners (NSAIDs, fish oil, etc.) for an additional 48 hours unless medically required
- Sleep with head elevated the first night if comfortable
- Apply cold compresses gently to the forehead if mild swelling develops (do not apply directly to injection sites)
- Do not pick at any small scabs or crusts that form
- Continue any concurrent hair regimen (minoxidil, finasteride, etc.) as directed by my provider
Call Navara Health Immediately For
- Spreading redness, fever, drainage, warmth, or worsening pain (possible infection)
- Severe headache or neurologic symptoms following lidocaine use
- Persistent severe scalp pain beyond the first 48 hours
- Significant facial or eyelid swelling
- Allergic reaction (hives, facial swelling, breathing difficulty)
For life-threatening symptoms (anaphylaxis, severe systemic anesthetic reaction), call 911 first, then notify Navara Health.
No Guarantee of Results
- Outcomes vary significantly between individuals based on genetics, hormone status, underlying scalp health, nutritional status, age, and adherence to recommended protocols
- No guarantee of hair regrowth, density change, thickness improvement, or any specific cosmetic outcome is provided
- Additional or ongoing maintenance treatments may be required and are at additional cost
- Results may be subtle, gradual, or absent despite appropriate clinical care
- The presence of androgenetic alopecia and other genetic patterns may limit response
Alternatives
Alternatives to Vampire Hair Restoration® include, but are not limited to:
- No treatment
- Topical therapies (minoxidil)
- Oral pharmaceuticals (finasteride, dutasteride, oral minoxidil, spironolactone — as clinically appropriate)
- Low-level laser therapy (LLLT) devices
- Microneedling alone
- PRP alone (without the full Vampire Hair Restoration® protocol)
- Surgical hair transplantation (FUE or FUT)
- Nutritional and hormonal evaluation and optimization
- Scalp camouflage or scalp micropigmentation
Financial Disclosure
- Vampire Hair Restoration® is elective and not covered by insurance
- Navara Health is a cash-pay practice for aesthetic and regenerative services
- Payment is due at the time of service
- No refunds are issued once the blood draw has been performed or PRP has been prepared and any portion of the protocol has been initiated
- Pre-paid treatment series and packages are non-refundable except as expressly stated in writing
- Maintenance treatments and additional sessions are at additional cost
- Treatment of complications, including antibiotics or specialty referral, may incur additional cost
Communication & HIPAA Authorization
I authorize Navara Health to communicate with me regarding scheduling, pre/post-procedure instructions, follow-up, and adverse event reporting through:
- The secure HIPAA-compliant patient portal
- Email to the address I have provided
- SMS / text message to the mobile number I have provided
- Telephone calls to the number I have provided
I understand that email and SMS are not fully secure channels. I may revoke authorization for any specific channel in writing to contact@navarahealthtx.com, except where required for legally mandated notices.
Assumption of Risk & Release of Liability
I voluntarily assume all known and unknown risks associated with Vampire Hair Restoration® and any optional add-on components. To the fullest extent permitted by law, I agree to release, indemnify, and hold harmless Navara Health, PLLC, Jessica Boggs APRN, the medical director, and all affiliated providers, nurses, contractors, staff, and supervising physicians from liability related to:
- Adverse reactions or complications
- Lack of improvement or treatment failure
- Cosmetic dissatisfaction with the result
- Need for additional, corrective, or maintenance procedures
- Long-term or delayed effects not yet known to medicine
- Conditions not disclosed prior to treatment
This release does not apply to cases of gross negligence or willful misconduct, and does not waive any right that cannot lawfully be waived under the laws of the State of Texas.
Dispute Resolution & Binding Arbitration
Any dispute, controversy, or claim arising out of or relating to this Consent, the procedure performed, or the practitioner-patient relationship — including any claim of medical malpractice, billing dispute, or breach of contract — shall first be addressed by good-faith negotiation between the parties.
If the matter cannot be resolved through negotiation within thirty (30) days, the parties agree to submit the dispute to binding arbitration administered by a recognized arbitration body (such as the American Arbitration Association) under its applicable rules, with the arbitration to take place in Dallas County, Texas.
The parties acknowledge that by agreeing to arbitration, they are waiving the right to a jury trial. This provision does not waive any right that cannot lawfully be waived under Texas law. Either party retains the right to seek injunctive or equitable relief in court where appropriate.
Governing Law & Severability
This Consent shall be governed by and construed under the laws of the State of Texas. If any provision is found unenforceable, the remaining provisions shall remain in full force and effect.
Procedure Components — Selection at Consent
Please initial each component I am consenting to receive at this visit. The PRP component is core to the Vampire Hair Restoration® protocol; microneedling and anesthetic options are individualized.
Core · Required
I consent to Platelet-Rich Plasma (PRP) scalp injection, including the necessary blood draw and centrifuge processing as part of the Vampire Hair Restoration® protocol.
Optional
I consent to scalp microneedling as an adjunct to PRP, performed during the same visit.
Optional
I consent to use of BLT topical anesthetic (benzocaine, lidocaine, tetracaine) on my scalp prior to the procedure.
Optional
I consent to use of injectable lidocaine, including possible admixture of small amounts of lidocaine into the PRP preparation.
Patient Initials — Required for Each Critical Clause
Each of the following requires my separate written initials. By initialing, I confirm that I understand and agree to each individual clause.
I understand that PRP does not create new hair follicles, that results are gradual over 3–6 months, and that no specific outcome is guaranteed.
I understand that temporary shedding ("shock loss") may occur after treatment and is not necessarily a sign of treatment failure.
If I have selected anesthetic options, I understand the specific risks of lidocaine systemic toxicity (LAST), methemoglobinemia, and allergic reaction described in Section 4.
I understand that a series of 3–6 treatments is typically required and that maintenance treatments every 6–12 months may be needed at additional cost.
I understand that no refunds are issued once the blood draw has been performed or any portion of the protocol has been initiated.
I agree to binding arbitration as described in Section 12 and understand that I am waiving the right to a jury trial.
Photography & Marketing Authorization
Photographs of the scalp and hairline taken before, during, and after Vampire Hair Restoration® serve different purposes, and I am being asked to provide separate consent for each use. I understand I may consent to medical documentation while declining marketing use, or vice versa.
Photography Use — Please Initial Each Option
Required · Medical Documentation
I consent to clinical photographs of my scalp and hairline being taken before, during, and after services for the purpose of medical documentation, treatment planning, progress tracking, and inclusion in my confidential medical record. These photographs will not be shared outside the practice without further written authorization.
Optional · Marketing & Promotional Use
I additionally authorize Navara Health, PLLC to use my before/after photographs in marketing materials, including the practice website, social media (Instagram, Facebook, TikTok, etc.), printed materials, advertisements, and educational content. My face or identifying features may be visible in these images. No compensation will be provided. I may revoke this authorization at any time in writing, and Navara Health will stop using the images going forward, though I understand previously published images cannot always be recalled from third parties or the internet.
Optional · De-Identified Marketing Use Only
I authorize use of my before/after photographs in marketing materials only with my face and identifying features de-identified (eyes/identifying features cropped or obscured; scalp images framed to exclude my face). I do not authorize identifiable images for marketing.
Optional · Provider Education & Conferences
I authorize use of my before/after photographs (identifiable or de-identified, as initialed above) in professional education contexts, including conferences, clinician training, CMA-affiliated education, peer education, and published case reports.
Patient Signature (Photography & Marketing)
Patient Acknowledgment & Electronic Consent
By signing below (or by typing my full legal name as an electronic signature), I acknowledge and affirm:
- I am at least 18 years of age or legally authorized to consent.
- I have read this Vampire Hair Restoration® Informed Consent in its entirety.
- I fully understand the procedure, its core and optional components, risks, benefits, limitations, and alternatives.
- I understand that Vampire Hair Restoration® is a CMA-trademarked protocol performed by a CMA-certified clinician.
- I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.
- I have disclosed my complete medical history, allergies, medications, supplements, recent procedures, and any scalp conditions.
- I understand the specific risks of any anesthetic options I have selected.
- I understand that PRP does not create new hair follicles and that results are not guaranteed.
- I accept full financial responsibility and understand that no refunds are issued once the protocol has been initiated.
- I authorize communication through the channels described in Section 10.
- I voluntarily assume all known and unknown risks and agree to the release of liability described in Section 11.
- I agree to binding arbitration as described in Section 12 and understand that I am waiving the right to a jury trial.
- I have completed the Procedure Components Selection, the Patient Initials block, and the separate Photography & Marketing Authorization above.
- I voluntarily consent to Vampire Hair Restoration® at Navara Health, PLLC.
- My typed name serves as my legal electronic signature, equivalent to a handwritten signature, and this consent becomes part of my permanent medical record.
Treatment Session (Visit # of Series)
Patient Signature (or Typed Electronic Signature)
Provider Signature — Jessica Boggs, APRN, FNP-C, ENP-C (CMA-Certified)