Facial Consent Form

Facial Consent Form

IMPORTANT: ACCURATE COMPLETION REQUIRED

Complete all sections of the consent form electronically.
Ensure a witness (a friend or family member is acceptable) is present to fill out their required sections clearly and legibly.
ALL fields, including the witness’s details, must be fully completed before submission.

Please write the full name of the procedure and the exact area being treated. Specify 'Right,' 'Left,' 'Upper,' or 'Lower' where applicable (e.g., 'Abdomen Upper' instead of 'Abdo'). ABBREVIATIONS ARE NOT ALLOWED.

You can copy and paste this information directly from your quote invoice, which has been emailed to you.

ONLY SIGN IF YOU FULLY AGREE AND UNDERSTAND

I

First Name: *

Last Name: *

Date of Birth: *

agree to undergo

I fully understand the procedure *

Possible outcomes - both short and long term *

Risks specific to the patient - inclusive of the possible impact of comorbities/patient history (can affect results) *

Anaesthesia includes:

- Tumescent/local
- IV Sedation
- I understand the risks involved in the above

INITIAL *

Oral analgesia will be provided post operatively *

Recovery times and specific care requirements *

I have read and fully understand the following possible risks, complications and details of the procedure.

Risks and Complications that are possible include:

Redness *

Swelling *

Bruising *

Hematoma (blood collection) *

Infection or allergic reactions *

Scarring *

Adjacent structure injury (nerve, muscle, blood vessels, teeth, glands etc) *

Eye irritation (dry, watery, damage) *

Visual loss *

Asymmetry (left side not equal to right) *

Muscle weakness (eyelid, mouth, brow etc) or paralysis *

Bleeding *

Pain (late or immediate onset) *

Clots in legs, lungs or death *

Failure and need for revision procedure/s or further treatment in both the short and long term (including extra cost) *

Unexpected complications unrelated to procedure (falls etc) *

Pigmentation increase or permanent loss *

Lumpiness, divets, new wrinkles *

Exacerbation of psychiatric and/or psychological conditions *

Risk of interruption to work, travel and social schedules *

Skin death (necrosis) *

Granulomas (allergic lumps) *

Septicaemia (blood poisoning) *

Systemic collapse/aggravation of illness *

I understand all the above risks and complications and have been given adequate opportunity to have my questions answered *

I agree to follow all preoperative and postoperative instructions including cessation of smoking *

I understand upon discharge my carer takes responsibility for my general care and will supervise me closely including excluding me from driving (and similar activities) and important decisions for the first 24 hours *

I agree to report any physical or psychological concerns immediately and allow Dr Murray to manage any of those that relate to my procedure *

Pre- and post-operative photographs will be taken of the treatment site for record-keeping purposes. I understand that these photographs/videos will be the property of the Medical Director. Choose one:

I DOI DO NOT

agree to allow these photographs to be used for publication or teaching purposes. If I agree I understand that my identity will be kept confidential and protected. Clinical photographs will be stored in a dedicated iPad.

Having discussed the reasonable expectations of my procedure with me, and having had all my questions answered to my satisfaction, I authorise Dr Glenn Murray and assistants of his choice, to perform this procedure and any other procedure(s) that in their judgement may be necessary or advisable should unforeseen circumstances arise during surgery. I understand that the practice of medicine is not an exact science and although good results are expected, there can be no guarantee as to the results.

I understand that photographs will be used solely for clinical purposes unless I have explicitly given my consent by signing a separate photograph release form. I am responsible for taking my own photographs for my records.

INITIAL *

Agreement to treatment. *

Your procedure will be performed at Suite 1/21 Stirling HWY, Nedlands, WA, 6009. *

Patient/Substitute Decision Maker Full Name *

Patient/Substitute Decision Maker Signature *

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Date *

Consent needs to be signed at least 7 days prior to surgery. *

A copy of the signed consent has been provided to me. *

Witness Full Name *

Witness Signature *

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Date *

I certify that I have discussed all of the above with the patient and have answered all the questions regarding the procedure, I believe the patient fully understands what I have explained and answered.

Doctor’s Full Name

Doctor’s Signature

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Date

Dr. Glenn Murray

Registered Medical Practitioner (MED0001196978)

Medical Fellow of ACCSM - Australasian College of Cosmetic Surgery and Medicine.

Interpreter’s Declaration (if applicable)

Specific language services required

I declare that I have interpreted dialogue between the patient and doctor/ healthcare provider to the best of my ability, and have advised of any concerns about my interpreting of this dialogue.

Interpreter’s Full Name

Interpreter’s Signature

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Date

Agency name

doc_368 V3 02/2025