Vampire Facial^®

Authorization for Treatment

I authorize Jessica Boggs, APRN, and qualified clinical staff acting under her supervision at Navara Health, PLLC, to perform the following components of the Vampire Facial® procedure:

• Evaluate my skin, medical history, and candidacy for treatment
• Perform venipuncture and draw my blood
• Process platelet-rich plasma (PRP) or platelet-rich fibrin matrix (PRFM) from my own blood
• Perform microneedling of the skin with a sterile, single-use needle cartridge
• Apply and/or inject PRP/PRFM into the treated skin as clinically appropriate
• Use topical or injectable anesthetics if deemed necessary
• Take clinical photographs for documentation and inclusion in my medical record
• Provide adjunctive measures (e.g., calming masks, topical antiseptics, post-procedure skincare) as appropriate

Description of the Vampire Facial® Procedure

The Vampire Facial® is a non-surgical skin rejuvenation procedure developed by Charles Runels, MD, that combines:

• Microneedling — controlled micro-injuries to the skin using a sterile needle cartridge, stimulating collagen and elastin production
• Autologous PRP or PRFM — derived from my own blood and processed immediately prior to treatment, applied topically and/or injected into the skin to enhance the healing and regenerative response

Potential treatment goals may include improvement in:

• Skin tone, texture, and luminosity
• Fine lines and superficial wrinkles
• Collagen and elastin regeneration
• Acne scarring or surface irregularities
• Pore appearance
• Pigmentation irregularities

I understand that:

• Results are not immediate and may take weeks to months to appear
• Multiple sessions are typically recommended (a series of 3 or more is common)
• Maintenance treatments may be necessary to preserve results
• My final results depend on adherence to aftercare and overall skin health

Sterility, Infection Control & Autologous PRP

I understand that, despite these precautions, no aesthetic procedure involving needles and skin penetration is risk-free. I have been given the opportunity to ask questions about infection control practices.

Risks & Potential Complications

Microneedling and PRP-based procedures carry inherent risks, even when performed properly.

I understand that complications may require additional treatment, prescription medications, or referral to specialty care, and may result in additional cost for which I am financially responsible.

Acknowledgment of Additional Risks & Limitations

I acknowledge and understand that:

• Unanticipated or rare complications may occur, even with appropriate screening and technique
• Medicine and aesthetic treatments are not exact sciences
• Individual healing responses vary and cannot be predicted
• No provider can guarantee cosmetic outcomes, satisfaction, or duration of results
• Additional or corrective treatments may be required
• I may be dissatisfied with the result, and dissatisfaction alone does not constitute substandard care

Off-Label Use Disclosure

I understand and acknowledge that:

• The cosmetic use of PRP/PRFM in microneedling is considered off-label
• Off-label use is legal, common, and accepted in medical practice but is not specifically FDA-approved for facial rejuvenation
• No representations have been made that PRP/PRFM is FDA-approved for cosmetic enhancement
• Off-label use does not mean experimental or unsafe

Alternative Treatment Options Include (but are not limited to)

• No treatment
• Prescription or topical skincare regimens (tretinoin, growth factors, exosomes, etc.)
• Microneedling without PRP
• Laser or energy-based resurfacing
• Chemical peels
• Injectable treatments (filler, neuromodulators)
• Surgical procedures

Local Anesthesia Consent

If topical or injectable anesthetics (such as compounded numbing cream or lidocaine) are used during the procedure, I understand potential risks include:

• Temporary burning, stinging, or discomfort at application
• Bruising or swelling
• Allergic reaction or contact dermatitis
• Local irritation
• Vasovagal response
• Seizure or systemic toxicity (very rare, dose-related)

I consent to the use of anesthetics as deemed appropriate by the provider for comfort and safety.

Pre- and Post-Procedure Responsibilities

Contraindications & Cautions

The Vampire Facial® may not be appropriate, or may require delay, if I have or disclose:

• Active acne flare, cold sore, herpes simplex outbreak, or other skin infection on the treatment area
• Active eczema, psoriasis, or rosacea flare on the treatment area
• Open wounds, abrasions, or sunburn on the treatment area
• History of keloids or hypertrophic scarring
• Recent isotretinoin (Accutane) use within the past 6 months
• Pregnancy or breastfeeding
• Active cancer treatment (chemotherapy, radiation to the area)
• Bleeding disorders or current anticoagulant therapy
• Recent injectable treatments, peels, or laser procedures in the treatment area

Before the Procedure

• I will disclose all medications, supplements, and recent skin treatments
• I will avoid NSAIDs, fish oil, vitamin E, and alcohol for 48–72 hours before (unless medically required)
• I will arrive with clean skin, free of makeup if instructed
• I will notify the provider of any cold sore history (prophylactic antiviral may be recommended)
• I will avoid sun exposure and tanning beds for at least 1 week before

After the Procedure

• I will follow all written aftercare instructions provided
• I will not wash my face, apply makeup, or use active skincare (retinoids, acids, vitamin C) for at least 24 hours, or as directed
• I will avoid strenuous exercise, saunas, hot tubs, swimming, and significant sun/heat exposure for at least 24–72 hours
• I will use only the gentle cleanser and recovery products recommended for at least 3–5 days
• I will apply broad-spectrum SPF 30+ daily and avoid direct sun exposure for at least 2 weeks
• I will not pick, scrub, or exfoliate peeling skin
• I will avoid chemical peels, lasers, waxing, and other facial treatments for at least 2 weeks
• I will report worsening pain, spreading redness, drainage, fever, or any vision change immediately

Financial Disclosure

I understand and agree that:

• The Vampire Facial® procedure is elective and not covered by insurance
• Navara Health is a cash-pay practice and does not bill, verify, or submit claims to insurance, Medicare, or Medicaid for aesthetic services
• Payment is due at the time of service
• No refunds are issued once the procedure has begun (including blood draw, PRP/PRFM processing, or initiation of microneedling)
• Treatment of complications, prescription medications, or referrals to specialty care may incur additional cost that is my financial responsibility
• Touch-up, series pricing, or maintenance procedures are separate billable services

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 the Vampire Facial® procedure. 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, staff, contractors, and agents from liability for:

• Adverse reactions or complications
• Side effects
• Unexpected outcomes
• Lack of benefit or visible improvement
• Cosmetic dissatisfaction with the result
• The need for additional, corrective, or maintenance procedures

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.

Photography & Marketing Authorization

Photographs taken before, during, and after the Vampire Facial® procedure 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.