Cosmetic Injectable Consent Form Patient Details Name: Email: Mobile: Date of Birth: Address: GP Details Name: Phone: Address: Medical History Do you have any medical history? Do you have allergies? E.g., bees/wasps, local anaesthetic/lignocaine, soybeans, blood products, salmon, or anything else? Are you currently taking any prescribed medications, blood-thinning medications, or over-the-counter medications? Have you taken antibiotics/steroids in the past 14 days? YesNo Are you currently pregnant, breastfeeding, trying to fall pregnant, or undergoing IVF treatment? YesNo Are you currently under investigation with your GP or specialist for any health concerns, including cosmetic screening investigations? YesNo Have you had any recent surgeries, dental procedures, vaccinations, or are you planning any? Are you blind in one eye? YesNo Do you have any skin disorders, acne, or infections in the facial area? Cosmetic Medical History Have you had cosmetic procedures before, such as Anti-Wrinkle, Dermal Filler, Facelift, Rhinoplasty, or any facial surgery? If so, please list. Have you ever been declined for cosmetic treatment by another practitioner? YesNo Have you ever experienced skin reactions (e.g., hives, excessive swelling, bruising) from injections or non-surgical procedures? YesNo Have you been injected with dermal filler outside Australia, or do you have facial implants (e.g., Aquamid, silicone)? YesNo Are you planning on travelling overseas or attending major events in the next 14 days? Financial Consent Cosmetic non-surgical procedures, including but not limited to anti-wrinkle injections, dermal fillers, fat-dissolving treatments, skin rejuvenation therapies, and regenerative medicine biostimulators, typically require ongoing treatments to achieve and maintain optimal results. Individual outcomes vary significantly, and a treatment plan may involve multiple sessions or procedures beyond those explicitly mentioned above. Cosmetic procedures are elective and not covered by Medicare or private health insurance. Accordingly, all associated costs are covered by the patient. You understand and confirm the following: * “Before and after images” reflect real results from real patients, although individual results will vary. * No guarantees or assurances have been made or promised regarding the results of any treatment, as outcomes depend on individual circumstances. * No guarantees were made in relation to the estimated treatment duration and the number of treatments required as individual experiences and results vary. * That an administration or Telehealth fee may be charged for the consultation with Medical or Nursing Practitioners. * That by providing my email address and mobile phone number in this document, you consent to receive communications related to this procedure, including but not limited to this consent form, reminders for this and future treatments, and post-procedure care instructions, via the contact details I have provided. Financial Consent Acknowledgment: I acknowledge and agree to the financial consent terms. Treatment Consent Agreement 1. Nature of Treatments I acknowledge that the treatments provided are elective cosmetic procedures with inherently subjective outcomes that may vary between individuals. 2. Results and Expectations While I have been informed of the expected outcomes, no guarantees or assurances regarding the results have been made or implied. I understand that achieving the desired outcome may require multiple appointments or treatments. 3. Risks and Complications I understand that complications can occur, and I accept this possibility. Further, I confirm that all potential risks, complications, and benefits of the treatments have been explained to me comprehensively. I am aware that alternative options, including no treatment, are available to me, and I have made the decision to proceed with the treatment myself. I confirm that I am undergoing these treatments voluntarily and without coercion. 4. Practitioner's Discretion My treating Registered Health Practitioner reserves the right to decline any requested treatment deemed inappropriate or unsuitable following an assessment. 5. Dosage and Fees The recommended dosages are tailored to my individual circumstances, and I understand dosage requirements vary between individuals. Additional dosages or treatments, if required, will incur additional fees. 6. Psychological Considerations I acknowledge that cosmetic procedures may affect pre-existing mental health conditions, such as body dysmorphia, anxiety, depression, low self-esteem, OCD, or PTSD. If I experience psychological distress following treatment, I will consult my General Practitioner. 7. Information and Instructions I confirm I have had the opportunity to seek alternative medical advice and have received sufficient information about the treatments and products. I have reviewed and understand the post-care instructions provided for my treatment(s). 8. Contraindications and Follow-up I have disclosed any contraindications to the treatments. If I experience pain, side effects, or other concerns, I will promptly contact my treating cosmetic nurse or visit the clinic. 9. Additional Acknowledgments I understand that medications, including metabolism boosters or weight-loss treatments (e.g., Duromine, Ozempic, Saxenda), may impact the efficacy and duration of the treatments. Recovery timelines, risks, and required care for complications vary per individual, and related costs, including specialist fees, are my responsibility. I acknowledge that Medicare or private health insurance does not cover cosmetic procedures. 10. Consent I consent to today's cosmetic procedure(s) and any subsequent treatments as deemed necessary by my practitioner. I agree to my before-and-after images being used for medical records and consent to the release of patient notes to medical teams or specialists as needed. Treatment Consent Acknowledgment: I understand and consent to the treatment as outlined in the agreement. Waiver and Release of Liability In consideration of receiving treatments or services from Hint Venture Capital Pty Ltd, trading as Body Contour Studio (the "Clinic"), I, the undersigned participant, acknowledge and agree as follows: 1. Assumption of Risk I am fully aware that the treatments and services provided by the Clinic involve inherent risks, including but not limited to injuries, complications, or adverse outcomes. I voluntarily assume all risks associated with the treatments and services. These include, but are not limited to, physical or psychological injury, economic loss, or emotional distress. This assumption of risk also covers injuries or losses occurring during travel to and from the Clinic or any related events. 2. Release and Waiver of Liability I release and forever discharge the Clinic, its owners, officers, employees, contractors, agents, prescribing doctors and affiliates (collectively, the "Released Parties") from any claims, demands, or actions arising from the treatments or services, including negligence or omissions by the Released Parties. This waiver extends to all known and unknown claims arising directly or indirectly from my participation in the treatments or services. 3. Indemnification I agree to indemnify and hold the Released Parties harmless against any claims, liabilities, costs, or expenses (including legal fees) resulting from my participation in the treatments or services, including claims brought by third parties. Should litigation arise due to any claims I or others make against the Clinic, I agree to reimburse all legal and related costs incurred by the Clinic. 4. Medical Clearance I certify that I am physically and mentally fit to undergo the treatments or services and have not been advised otherwise by a qualified medical professional. I understand that any pre-existing conditions, medications, or other health factors may impact the outcomes of the treatments. 5. Acceptance of Responsibility I acknowledge that the procedures may result in permanent physical changes and carry risks of adverse effects. I accept full responsibility for any outcomes, including complications or dissatisfaction with the results, and I release the Clinic from liability for such outcomes. I understand that treatments are elective, cosmetic in nature, and do not guarantee specific results. 6. Voluntary Participation My decision to undergo treatments is entirely voluntary. I acknowledge that I have had the opportunity to seek alternative advice and explore other treatment options, including the option to decline treatment. 7. Governing Law This agreement is governed by the laws of New South Wales (NSW), Australia, and any disputes shall be resolved in accordance with NSW law. 8. Arbitration Clause Any disputes relating to malpractice or any legal issues due to the treatments provided shall be resolved through binding arbitration under the NSW Arbitration Act. Each party will bear its own legal costs, and arbitrator fees will be shared pro-rata. Filing a legal action to collect unpaid fees does not waive the right to arbitration for malpractice claims. 9. Severability If any provision of this agreement is deemed invalid or unenforceable, the remaining provisions will remain in full force and effect. 10. Financial Responsibility I acknowledge that I am responsible for any costs arising from medical care required due to adverse effects or complications resulting from the treatments. This includes specialists or doctors’ fees, medication or any further treatment. I understand that additional treatments to address complications may incur extra charges. 11. Acknowledgment and Acceptance I confirm that I am at least 18 years old, have carefully read and fully understand this waiver, and voluntarily agree to its terms. By signing this document, I acknowledge that I am relinquishing certain legal rights, including the right to sue the Clinic for claims arising from my participation in treatments or services. I acknowledge and agree to the following: * I am fully aware that the treatments and services provided by the Clinic involve inherent risks, including but not limited to injuries, complications, or adverse outcomes. * I voluntarily assume all risks associated with the treatments and services. These include physical or psychological injury, economic loss, or emotional distress. * I release and forever discharge the Clinic, its owners, officers, employees, contractors, agents, prescribing doctors, and affiliates from any claims, demands, or actions arising from the treatments or services, including negligence or omissions. * I agree to indemnify and hold the Released Parties harmless against any claims, liabilities, costs, or expenses resulting from my participation in the treatments or services. Waiver and Release of Liability Acknowledgment: I have read and agree to the waiver and release of liability. Informed Consent Informed Consent for Botulinum Toxin Type A Botulinum Toxin Type A is listed on the Australian Register of Therapeutic Goods (ARTG) for cosmetic use in treating frown lines, crow’s feet, and forehead lines. Botulinum toxin Type A can also be used for facial symmetry and cosmetic improvement. The purpose of Botulinum toxin type A treatment is to weaken the treated muscle(s) and help prevent the formation of expression lines. The procedure involves the injection of Botulinum toxin type A, by injection, into the muscle located at the desired treatment area. When Botulinum Toxin Type A is injected into a muscle, it causes weakness in that muscle and prevents the muscles that is treated to reduce function, allowing the expression lines to dissipate or reduce. The dosage of Botulinum Toxin Type A that is injected may vary from patient to patient and will depend on the patient’s presentation, history, and desired outcome. The procedure is completed by a registered nurse, following a consultation with a doctor or Nurse Practitioner. The procedure can take up to 14 days to be effective, and typically lasts between 2 to 4 months depending on how a patient’s body responds to the procedure. The muscles injected will not function whilst the injection is effective, and this effect may begin to reverse itself after a period of 3-4 months. Once the effectiveness has worn off, patients may wish to consult at Juvae for re-treatment. The most common side effects associated with the use of Botulinum Toxin type A include, but are not limited to: Swelling, Bruising, Infection, Temporary eyelid/eyebrow drooping, Muscle atrophy, Headache. Other side effects may include Dry Mouth, Tinnitus, Erythema multiforme, Anorexia, Vision blurred, Visual disturbance, Hypoacusis, Dysarthria, Paresthesia, Pyrexia, Malaise, Myalgia, Myasthenia gravis, Radiculopathy, Syncope, Hypoesthesia, Facial paresis, Facial palsy, Strabismus, Vertigo, Peripheral Neuropathy, Pruritus, Diarrhea, Dermatitis psoriasiform, Alopecia including madarosis, Abdominal pain, Nausea and/or vomiting, and Brachial plexopathy. Generalised side effects may occur such as rash, itchiness, allergic reactions, flu like symptoms, hypertrophic scars/keloids and tightness. Long term use of Botulinum Toxin can divert muscle atrophy. I acknowledge and accept that Botulinum Toxin Type A treatment applied to my forehead area may only last between 6 to 8 weeks and once the effectiveness has worn off, I may be able to undergo further treatment. Long term side effects: - Some patients build up antibodies to anti-wrinkle treatment(s). In the event this occurs, other treatment options may be offered to me at an additional charge. If I do not respond to further treatment, then I will be precluded from undergoing anti-wrinkle treatment for 18 months and I will not receive a refund. In the event that your body builds up antibodies to Botulinum Toxin Type A, you may not be able to use this medication for therapeutic use in the future. Anti-wrinkle Botulinum Toxin Treatment has been used in patients for over 20 years worldwide. Informed Consent for Hyaluronic Acid Hyaluronic Acid is a natural substance (a complex sugar) that stabilises the skin structure, attracts and binds water, and contributes to the elastic properties of the skin that allow it to remain tight. Injections of Hyaluronic Acid into the skin are thought to replenish its natural support structures damaged by ageing, filling in facial wrinkles and hollows, and for lip augmentation. Patients initially may observe swelling in the treatment area. It may take up to three days to see any results. The effect of Hyaluronic Acid generally lasts for 4 months or longer and will require follow-up treatments to maintain results. Patients should not apply make-up for 24 hours after the injection, and should avoid prolonged exposure to sunlight, UV light, freezing temperatures or using saunas or Turkish baths for two weeks after the injection. Patients are recommended not to wear any restrictive headwear including Goggles, and large sunglasses. It is recommended that patients avoid facedown massages or facial treatment(s) that involve pressure. Patients should not undergo any laser treatment(s) to the area for one month post injection. Side effects associated with the use of Hyaluronic Acid treatment may be immediate or up to 10 years post treatment include, but are not limited to: Redness, Bruising, Swelling, Infection, Itching Sensation (in treated area), Tightness, Nerve Damage, Bumps, Lumps, Pimples, Tenderness, Cold sore outbreak, Pressure, Tissue Scarring, Pain, Immune response Very rare cases of side effects associated with Hyaluronic Acid include: Irreversible discoloration, Abscess (hard and swollen sore that may contain pus), Stroke, Exacerbate the asymmetry of the treated area, Vascular occlusion/Necrosis, Granuloma (small accumulation of tissue), Blindness, Hypertrophic scars/keloids In the event you are not located in a major city or near a specialised Eye Hospital, reversal of side effects may not be possible. Although the risk of developing a serious complication is small, should a complication occur, the Registered Health Practitioner involved in your treatment will use their best medical judgement to do whatever is necessary to treat the problem. In the event that any Hyaluronic Acid is over filled or attracts excess fluid in the area treated, it may need to be dissolved. If you experience any discomfort/discoloration as a result of treatment, you should immediately notify the Registered Health Practitioner involved in your treatment. In the event of an adverse reaction, the administration of the medication Hyaluronidase or surgery may be required. If the administration of the medication Hyaluronidase or surgery is required, this will be at the expense of the patient. In the event any complications occur, several appointments at different clinic locations may be required to treat the area affected. I agree and understand that Hyaluronic Acid injected to any treatment area: (i) will only give minor improvement to volume loss, (ii) will in no way treat or improve pigmentation or dark circle under the eyes, (iii) may cause migration, (iv) may require several treatments to achieve the desired outcome. Hyaluronic Acid Dermal Filler Treatment has been used in patients for over 15 years. In the event Hyaluronic Acid complication occurs an agent known as Hyaluronidase may be used to dissolve the filler. Hyaluronidase is an enzyme that breaks down hyaluronic acid and has been used in medical applications for over 60 years. For the correction of complication and unsatisfactory results after filler injections. Although good results are expected, the behavior of Hyaluronidase is unpredictable and therefore it is difficult to proceed with accuracy each time and every time. In some circumstances hyaluronidase can break down areas of natural Hyaluronic acid, as well as areas of Hyaluronic acid added through injection that you do not want removed. Volume loss, crepey skin or skin textural changes may occur. In the event of a poor response from the enzyme, the face may appear uneven as some areas may be greater affected by the enzyme than others. It is because of this that there is no guarantee on the results that can be obtained through treatment. As with any treatment, dissatisfaction remains a real risk. There is no guarantee that any form of resolution will be reached by using hyaluronidase. It is possible that these lumps, nodules, and other adverse effects are because of other factors including but not limited to; fibrous tissue, water retention, infection and cysts, instead of the product itself. I understand that the risks and side effects of Hyaluronidase include pain, itching or redness where the injection is given. Swelling in the hands, feet or other body areas may also occur, as well as a breakdown of the patient’s own Hyaluronic Acid and any Hyaluronic Acid in the area/s treated could need further dermal filler to revolumise the area. Rare side effects include cough, difficulty swallowing, hypersensitivity reaction, urticaria, angioedema, dizziness, fast heartbeat, hives or welts, skin rash or anaphylactic reaction. I authorise the registered nurse and Registered Health Practitioner involved in my treatment to administer Hyaluronidase in the event I have an adverse reaction or possible side effect to the injection of Hyaluronic Acid. I further acknowledge and accept that I have read and understood the above. In the event of adverse reaction to dermal filler it may be a requirement to have the product surgically removed at the patient’s expense. Informed Consent for Anaesthetic I have read the information regarding anaesthetic and understand the treatment risk and side effects. 1. Dizziness, nausea, vomiting, accelerated heart rate, slow heart rate, or various types of allergic reactions. any or all of these may require additional medical management or hospitalization. 2. Restricted mouth opening during recovery, sometimes related to muscle soreness at the site of the injection requiring physical therapy. 3. Prolonged numbness, that in some patients may result in injury from biting or chewing an area such as (lip, cheek, or tongue that has received the local anaesthesia. 4. Injury to nerves that can result in pain, numbness, tingling, or other sensory disturbances to the chin, lip cheek, gums or tongue. This may persist for several weeks, months, or rarely be permanent. Informed Consent for Rejuran Polynucleotides (PN) is designed to deliver bio-Activator solutions into the skin. The needle punctures the skin at controlled depths, this treatment is customised to you and can target skin concerns including fine lines, pores, scarring, stretch marks, skin tone and texture. It is suitable for all skin types and anywhere on the body. Polydeoxyribonucleotide (PDRN) & Polynucleotides (PN): Both PDRN and PN are extracted from salmon's DNA and are good for epidermis, dermis and extracellular matrix (ECM) regeneration. They help address fine wrinkles, pores, and improve skin texture. ADVERSE REACTIONS AND POSSIBLE COMPLICATIONS While there may be some initial slight swelling, small visible bumps or papules on the treated areas immediately after the treatment, this will subside within 24 hours, and you can go about your daily activities as usual. The following may occur: The procedure may result in minor redness, injection marks, small visible bumps, etc., this will subside within 1~3 days. Minor flaking, dryness and peeling which may last several days. Scabs may form but will fall off within a few days. Moderate erythema (redness), swelling and skin sensitivity (1~3 days). Possible Heat in area of treatment after alcohol consumption Development of infection that in rare cases could lead to scarring caused by picking, and failure to follow aftercare instructions. After the procedure, refrain from high-temperature entrances such as saunas. Excessive massage, such as scleroderma, should be avoided after the procedure. After the procedure, you should carefully apply sunscreen with a high SPF index to prevent pigmentation. The areas treated with Cross-linked HA filler and fat graft treatment less than a year are not recommended to treat Rejuran. Informed Consent for PRP You should not have PRP treatment done if you have any of the following conditions: Skin conditions and diseases including: Facial cancer, past and present. This included SCC, BCC and Melanoma, systemic cancer, chemotherapy, steroid therapy, dermatological diseases affecting the face (i.e. Porphyria), Blood disorders and platelet abnormalities, Anticoagulation therapy (i.e. Warfarin), Platelet dysfunction syndrome, critical thrombocytopenia, hyperfibrinogenaemia, haemodynamic instability, sepsis, chronic liver disease, Hepatitis or any acute or chronic infections. If you are pregnant, breast feeding, allergic to local anaesthetics, have any heart problems, anemia or methemoglobinema you may not be able to receive this treatment. I understand the risk and side effects are as follows: The possible risk and side effects include but not limited to moderate to severe swelling, brusing of the treated area, which can last up to 21 days, as well as hemotosis staining, which can be permanent. You may notice a tingling sensation while the cells are being activated, dizziness and fainting, scarring, Bleeding, Pinkness/Redness (flushing). In rare cases skin infection or injury to nerves or blood vessels, pigmentation changes to skin, scar tissue formation and calcification at injection sight may occur. There is the possibility that the BioFiller gel product could block a blood vessel if it is injected within a larger artery.. Side effects to topical Lignocaine can include rash, itch, redness and in rare cases there may be allergies I have read the information provided about the following treatments, including their risks and side effects: * Botulinum Toxin Type A * Hyaluronic Acid * Rejuran * Anaesthetic * PRP Informed Consent Acknowledgment: I consent to Botulinum Toxin Type A treatment. I consent to Hyaluronic Acid treatment. I consent to anaesthetic treatment. I consent to Rejuran treatment. I consent to PRP treatment. Additional Consent 1. Complaint Procedures In the event that you wish to lodge a formal complaint, you may contact the following regulatory bodies: * AHPRA (Australian Health Practitioner Regulation Agency) * The Health Care Complaints Commission (HCCC) or Medical Council of NSW (for patients in NSW) * Office of the Health Ombudsman (for patients in Queensland) 2. Acknowledgment and Consent to Treatment I have read and fully understand the information provided to me regarding today's cosmetic procedure and any subsequent treatments as recommended by the health practitioner and the nurse performing the procedure. * I understand that the health practitioner has discussed alternative treatment options, including the option of not undergoing treatment. * I acknowledge that the health practitioner may refuse treatment if they determine it is not in my best interest. * By signing this consent, I release and agree to hold harmless Hint Venture Capital Pty Ltd, trading as Body Contour Studio, and its staff from any claims of any nature arising from the treatments I receive. 3. Consent for Image Use I consent to the use of my before-and-after images for the following purposes: * Medical Consultation: My images may be accessed by the treating nurse or other medical professionals involved in my care. * Records Storage: My images will be securely stored as part of my patient records for reference purposes. * Internal Use: My images may be used for educational or medical consultation purposes as required. 4. Consent for Patient Notes I consent to the release of my patient notes to: * The Body Contour Studio Medical Team * Specialists or other healthcare professionals if required for my care. * My patient notes will be securely stored for reference and may be used for educational or consultation purposes. 5. Acknowledgment of Treatment Risks and Side Effects I confirm that I have read and understand the information provided to me about the following treatments, including their risks and potential side effects: * Botulinum Toxin Type A * Hyaluronic Acid * Rejuran * Anaesthetic * PRP 6. Voluntary Consent By signing this form, I confirm that: * I have been fully informed about the procedures and any associated risks. * I voluntarily consent to proceed with today's cosmetic procedure and any future treatments as recommended. * I understand that I have the right to ask further questions at any time. Additional Consent Acknowledgment: I acknowledge that I have been informed about complaint procedures. I acknowledge and accept the consent to treatment. I consent to the use of my images as described. I consent to the release of my patient notes as described. I acknowledge and accept the risks and side effects. I provide my voluntary consent to treatment. Date (required) Your Initials (required)