Patient Consent Form

Treatments Covered:
* Fat Freezing
* HIFU
* Fat Cavitation and Radio Frequency Skin Tightening
* PDO Threads
* Emshape

Patient Details

Full Name: (required)
Date of Birth (required)
Contact Number (required)
Email: (required)
Address: (required)
Date of Consent Signed: (required)
Your Initials: (required)

Your Doctor

GP Name (required)
GP Clinic (required)
GP Contact Details (required)

MEDICAL HISTORY

* Medical history or health concerns:

* Medications you are taking:

* Allergies:

* Previous Cosmetic Surgery:

* Blindness in one eye, Cancer, heart disease/hypertension, hypotension, Diabetes, kidney disorder, Thyroid illness , Chronic Fatigue, Hepatitis / HIV, Bells palsy, thrombosis, Hemorrhagic or bleeding disorder, Phlebitis, Hemophili. Hypoglycemia, Muscular Conditions NoYes
* Cold sores, asthma, skin disorder/acne or skin infections, herpes, any Active or local skin disease that may alter wound healing or Open or infected wounds, or any respiratory conditions, Hormonal Disorders. NoYes
* Impaired Skin sensation. NoYes
* Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy. NoYes
* Known sensitivity to cold such as cold urticaria, Raynaud’s disease, Cryoglobulinemia or paroxysmal cold hemoglobinuria? NoYes
* Myasthenia gravis, neurological disorder, Hasimoto's Disease, Eaton-Lambert syndrome, Bell's palsy, Crest syndrome/Scleroderma, Rheumatoid Arthritis, Epilepsy, Multiple Sclerosis, muscular weakness, Myasthenic syndrome or an autoimmune disease/Lupus, or Keloid scarring? NoYes
* Do you suffer from Diabetes with microangiopathy? NoYes
* Do you suffer from serious cardiac, renal of liver disease? NoYes
* Porphyria (skin condition) NoYes
* Underlying sepsis NoYes
* A hernia or history of hernia in the area to be treated. NoYes
* Have you had any surgery in the last 6 weeks? NoYes
* Have you had COVID-19 in the last 4 weeks? NoYes
* Are or have you had the Covid/Flu vaccine or Covid Booster within two weeks before/after? NoYes
* Have you had a Tetanus Vaccine within the last 6 weeks? NoYes
* Do you suffer from anxiety or depression or any mental health issues? NoYes
* Have you had major dental work in the last 4 weeks or are you planning on undergoing dental work in the next 2 weeks? NoYes
* Are you pregnant/breast feeding/intending to become pregnant or undergoing IVF treatment? NoYes
* Are you currently under investigation with your general practitioner or specialist for any health concerns? NoYes
* Are you allergic to local anesthetic, blood products, bee stings, eggs or soybeans? NoYes
* Are you allergic to anything else? NoYes
* Are you taking any of the following medication: Blood thinners/Aspirin, Herbal supplements/Fish Oils, NSAIDs, No Roaccutane, or Antibiotics? NoYes
* Are you on any other medications? NoYes
* Have you had Botox/Dysport/Xeomin, Dermal Filler or Biostimulator treatments in the last 4 weeks? NoYes
* Have you had Permanent Filler in the past 10 years? NoYes
* Are you planning on travelling overseas, or any major events in the next 2 weeks? NoYes
* Have you had fat dissolving injections to the face within the last 2 weeks? NoYes
* Do you suffer from blood disorders or are on warfarin or any blood thinners? NoYes
* Previous skin allergic type reaction/hives; excessive swelling or bruising from other facial injection procedures eg: PDO threads, PRP, HA filler. (this can help to predict the first phase of regeneration response) NoYes
* Use of oral corticosteroids within ten days prior to PRP procedure NoYes
* Allergies (to ingredients, substances, foods, Local Anesthetic etc.), including anaphylaxis NoYes
* Any metal stents or any implants in the area to be treated NoYes
* Do you have any implanted electrical devices? NoYes
* Undergone a surgical cosmetic procedure in the face or neck? NoYes

If you any of the above medical conditions, please urgently alert the team as soon as possible as you may need to get assessed by your GP to ensure your safety of proceeding with the treatment. If any of these conditions are deemed serious or not suitable for treatment, the staff at body contour studio will refuse to conduct your treatment.

FINANCIAL CONSENT

I understand that “Before and after images” reflect real results from real patients, although individual results will vary.
I confirm that no guarantees have been given or promised in relation to results as they vary per individual.
I confirm that no guarantees were made in relation to the estimated treatment duration and the number of treatments required as individual experiences and results vary.

AVERAGE RECOMMENDED TIMEFRAMES:

Face and Body Contouring treatment

PATIENT CONSENT:
I acknowledge and accept that:

* The treatment(s) performed are for cosmetic reasons and the result(s) can therefore only be assessed subjectively.
* While I have been advised as to the probable result, this can in no way be interpreted as a guarantee.
* Several appointments may be required to complete my desired outcome.
* Whilst complications from the treatment(s) are uncommon, they do sometimes occur.
* No guarantees of any nature can be made as to the result of the treatment(s).
* The complications and risks have been discussed with me in full.
* There are alternatives to the treatment(s) available such as accepting my present condition.
* I am undergoing the treatment(s) of my own volition.
* My treating Registered Health Practitioner can refuse to complete any treatment(s) that I request, provided my treating Registered Health Practitioner has assessed my request and reasonably determined it is not appropriate to conduct such treatment(s).
* The expert advice given by my treating Registered Health Practitioner about the recommended dosage(s) or treatment(s) is subject to my personal circumstances. I accept that recommended dosage(s) or treatment(s) vary from person to person.
* Should I require any additional dosage(s) or treatments I will be charged an additional fee.
* Cosmetic procedure(s) may cause me to suffer mental health symptoms or exacerbate any existing mental health conditions from which I may suffer. The mental health symptoms/conditions relevant to this include, but are not limited to, Body Dysmorphia, Anxiety, Depression, decrease of Self Esteem, Obsessive Compulsive Disorder, and/or Post Traumatic Stress Disorder. I acknowledge that if I experience any mental health conditions and/or symptoms following the treatment(s), I am to consult with my General Practitioner.
* I have been given the opportunity to seek alternative medical advice and have been given sufficient information about the treatment(s) and product(s) to be used during my treatment(s).
* I have been given post care treatment instructions, patients information and contact details.
* I have read the patient instructions thoroughly and was given the opportunity to raise any concerns that I may have.
* I have flagged any conditions that I may have which is a contraindication for the treatments.
* If I feel pain, experience any side effects, or have any other issues, I will immediately contact my cosmetic nurse.
* I confirm and understand that in the event of an adverse event, complication, or side effect, I may be required to take time off work and Body Contour Studio will not be liable as I understand all the risks and side effects associated with the treatments.
* I confirm and understand that in the event of an adverse event, complication or side effect further treatment may be required and will incur further financial expense. In the event a specialist is required, the fees may present from $250 per hour up to $5000 or more. I confirm that Body Contour Studio will not be liable as I understand all the risks and side effects associated with the treatments.
* In the event of an adverse event, complication, or side effect, in the event of adverse events, complication or side effect, recovery times and care requirements will vary from person to person.
* Cosmetic Procedures are not covered by Medicare or private health insurance.
* I understand that I may get a condition called paradoxical adipose hyperplasia and liposuction may be required. As such, I will release Body Contour Studio and forever discharge Body Contour Studio (including its officers, members, owners, employees, and agents) from all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself.
* I have read and fully understand the above information and consent to undergo today's cosmetic procedure and for any subsequent treatments as per the nurse performing the procedure.
* The health practitioner has discussed other options for treatment and the option of not having the procedure is discussed.
* I agree and consent to my before and after images to be accessed by the treating nurse, and by any Medical Team. My images will be stored in patient records for reference.
* I consent to my patient notes to be released to the any Medical Team or any specialists if required.
* My patient notes will be stored in patient records for reference.

Your Initials: (required)

WAIVER AND RELEASE OF LIABILITY
In consideration of participating in any treatments or services offered by Hint Venture Capital Pty Ltd, operating as Body Contour Studio (referred to as the "Clinic"), located at 38 Burringoa Crescent Colebee NSW 2761 Australia, I, the undersigned participant, hereby acknowledge and agree to the following:
* Assumption of Risk: I am aware that the treatments and services provided by the Clinic carry inherent risks and that injuries, accidents, or complications may occur during or as a result of these treatments. I voluntarily assume all risks associated with participating in the treatments or services offered by the Clinic. By participating in any of the treatments offered at Body Contour Studio (referred to as the "Activity"), I acknowledge the potential risk of injury. In consideration for the privilege of participating in the Activity, I willingly and voluntarily enter into this waiver and release of liability. I hereby waive any and all rights, claims, or causes of action arising from my participation in the Activity. Furthermore, I release and forever discharge Hint Venture Capital Pty Ltd, Body Contour Studio, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, and assigns from any physical or psychological injury, including illness, paralysis, death, damages, economic loss, or emotional loss that may occur as a direct result of my involvement in the Activity. This release encompasses any injuries or losses sustained during travel to and from events related to the Activity.

* Release and Waiver: I hereby release, waive, discharge, and covenant not to sue Hint Venture Capital Pty Ltd, Body Contour Studio, their affiliates, managers, members, officers, directors, employees, agents, contractors, and representatives (collectively referred to as the "Released Parties"), from any and all claims, liabilities, demands, actions, causes of action, costs, and expenses, including but not limited to medical expenses, attorney fees, and court costs, arising out of or in any way connected with my participation in the Clinic's treatments or services. This release applies to any and all claims, whether known or unknown, arising from the negligence, carelessness, or other acts or omissions of the Released Parties.

* Indemnification: I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all claims, liabilities, demands, actions, causes of action, costs, and expenses, including but not limited to medical expenses, attorney fees, and court costs, arising out of or in any way connected with my participation in the Clinic's treatments or services. This includes claims brought by third parties, as well as claims arising from my own acts or omissions. I agree to indemnify and hold Hint Venture Capital Pty Ltd, Body Contour Studio harmless against any claims, suits, or actions, including liability, medical negligence, damages, compensation, or other related costs, brought by me or anyone acting on my behalf. If litigation arises from any claims made by me or on my behalf, I will reimburse Hint Venture Capital Pty Ltd, Body Contour Studio for any expenses incurred.

* Medical Clearance: I certify that I am physically and mentally fit to participate in the treatments or services provided by the Clinic. I have not been advised by a qualified medical professional to refrain from participating in these treatments or services.

* I acknowledge that the treatments offered at Body Contour Studio can result in permanent changes and adverse consequences. I assume full responsibility for any personal injuries that may occur as a result of these treatments. In exchange for receiving these treatments, I release Body Contour Studio, including its officers, members, owners, employees, and agents, from any and all damages, costs, expenses, liabilities, causes of action, claims, and demands, whether known or unknown, direct or indirect, asserted or unasserted, arising from the treatments I have requested. This release extends to all parties whose claims may arise in connection with the treatments, including spouses, heirs, and children, whether born or unborn. Any legal claims related to the treatments will be governed by New South Wales (NSW) law. I agree to indemnify, hold harmless, and defend Body Contour Studio, including its officers, members, owners, employees, and agents, against any third-party claims, causes of action, damages, judgments, costs, or expenses, including attorneys' fees and other litigation costs, arising from the treatments I have requested.

* By signing this agreement (consent form), I confirm that I am at least 18 years old. I understand that the procedures involved in these treatments stimulate permanent changes and carry potential adverse consequences. I acknowledge that the procedures are purely for cosmetic purposes. I have read and fully comprehend this consent and procedure form. I consent to the indicated procedure(s) and accept full responsibility for any complications or outcomes that may arise during the procedures performed at my request. I understand that signing this agreement entails relinquishing certain legal rights.

* Voluntary Participation: I acknowledge that my participation in the Clinic's treatments or services is voluntary and that I have chosen to participate despite the known risks and potential complications.

* Governing Law: This waiver and release of liability shall be governed by and construed in accordance with the laws of the jurisdiction in which the Clinic is located.

* Severability: If any provision of this waiver and release of liability is deemed invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Arbitration

Full Name: (required)
Initial: (required)
Date Signed: (required)

TREATMENTS

Cryolipolysis/ Fat Freezing
The Cryolipolysis procedure utilises highly controlled cooling technology that can safely and effectively reduce and eliminate fat cells from specific areas of the body. Cryolipolysis can deliver significant fat layer reduction in these targeted areas which help to contour the body and reclaim its natural shape. You should not have the treatment if you have any of the following but not limited to: Cryoglobulinemia, Paroxysmal cold hemoglobinuri, Cold urticarial, Areas of impaired peripheral circulation, Raynaud's disease or Raynaud's phenomenon, diabetes, Liver Problems and Thin, frail skin.

I have read the information regarding Fat Freezing and understand the treatment risk and side effects.

HIFU
HIFU stands for High-Intensity Focus Ultrasound, HIFU is a non-surgical treatment that uses focused ultrasound technology to tighten and lift facial and body skin. HIFU effects 3 different layers of the superficial and dermis along with SMAS, which is the same layer of the tissue that surgeons pull tight in a facelift. As thermal energy safely heats this tissue, it contracts resulting in tightening of the skin and formation of new collagen, which provides a long-term tightening effect. HIFU directly delivers ultrasound energy to skin and subcutaneous tissue that can stimulate and renew the skin’s collagen and thus consequently improving the texture and reducing sagging of the skin. The procedure is completed by a registered nurse. The procedure can take up to 3 months to be effective. The most common side effects associated with HIFU but not limited to: Pain, blotchy skin, swelling, nerve inflammation, nerve pain, nerve damage, bruising, redness, numbness, hyper-pigmentation, Tingling or minor discomfort during treatments, people experience tingling for a few days to a week after treatment, burns, alteration of body. Infection, Tenderness, Headache. Nausea, stinging, temporary dulling, intense sensations, scarring, skin pigmentation, deep itching, tingling, soreness, or tenderness to the touch, mild to moderate pain or aching in the treated area, muscle spasms, redness, firmness, pinching sensation, skin sensitivity. Other side effects may include: pain that starts several days after the treatment and usually resolves when numbness goes away, or after about a month, scarring or changes to skin color, keloids, reduced movement or response of the tongue following procedures involving the neck or chin, lower lip muscle weakness following procedures involving the neck or chin, dizziness, light-headedness, sweating, painting, nausea, and flushing, hyperpigmentation, or dark skin coloration that often resolves on its own, undesirable changes in fat layering, damage to the facial nerve can cause facial paralysis and severely alter patients' esthetic appearances and speech functions.

I have read the information regarding HIFU and understand the treatment risk and side effects.

Fat Cavitation/ Radio Frequency Skin Tightening
Fat cavitation turns fat cells into liquid which can then be naturally drained by the body’s own natural filtration system. The cavitation hand piece transmits low level ultrasonic waves which consist of compression- expansion impulses that travel in high-speed cycles. This back and forth cycle then causes an infinite quantity of microcavities or micro-bubbles that gradually enlarge. This progressive enlargement finishes as microbubbles start to collide and implode, producing shock waves that favour emulsification and elimination of fat tissues. The liquid is then easily vacuumed out from the body using the lymphatic and urinary system. Radiofrequency (RF) energy is a new and promising technology for non-surgical tightening of the early signs of loose or sagging skin. RF procedure is primarily used to treat skin laxity by tightening and is best suited to patients with mild to moderate sagging of facial tissues, usually those in their mid-thirties to fifties, with any skin colour. RF is best used in conjunction with ultrasound cavitation to aid in further fat breakdown and also to tighten the skin in the same area the cavitation treatment has taken place. The procedure is completed by a registered nurse. The procedure can take up to 3 months to be effective. The most common side effects associated with Fat Cavitation and Radio frequency skin tightening but not limited to: Pain, blotchy skin, swelling, tinnitus, ringing in the ear, blocked ear, nerve inflammation, nerve pain, nerve damage, bruising, redness, numbness, hyper-pigmentation, Tingling or minor discomfort during treatments, people experience tingling for a few days to a week after treatment, burns, alteration of body. Infection, Tenderness, Headache. Nausea, stinging, temporary dulling, intense sensations, scarring, skin pigmentation, deep itching, tingling, soreness, or tenderness to the touch, mild to moderate pain or aching in the treated area, muscle spasms, redness, firmness, pinching sensation, skin sensitivity. Other side effects may include: pain that starts several days after the treatment and usually resolves when numbness goes away, or after about a month, scarring or changes to skin color, keloids, reduced movement or response of the tongue following procedures involving the neck or chin, lower lip muscle weakness following procedures involving the neck or chin, dizziness, light-headedness, sweating, painting, nausea, and flushing, hyperpigmentation, or dark skin coloration that often resolves on its own, undesirable changes in fat layering, damage to the facial nerve can cause facial paralysis and severely alter patients' esthetic appearances and speech functions.

I have read the information regarding Fat Cavitation and Radio frequency skin tightening and understand the treatment risk and side effects.

EmShape
EmShape is a non-invasive treatment and has no recovery time or any pre/post-treatment preparation. EmShape uses High Intensity Pulsed Electromagnetic therapy to create a muscle contraction stronger than you could ever achieve on your own. In each 30-minute session, you can achieve up to 20,000 contractions – the equivalent of up to 20,000 crunches/squats to strengthen and tone your inner core, sculpt your abs and glutes. This contraction does not involve muscle relaxation and the muscle works at its maximum capacity. These extreme contraction conditions require the muscle to adapt and develop muscular mass over the treated area and burn fat in the background. The procedure is completed by a registered nurse. The procedure can take up to 3 months to be effective. The most common side effects associated with Emshape but not limited to: Soreness, Pain, nerve inflammation, nerve pain, nerve damage, bruising, redness, numbness, Tingling or minor discomfort during treatments, Tenderness, Headache. Nausea, stinging, temporary dulling, intense sensations, mild to moderate pain or aching in the treated area, muscle spasms, redness, firmness, pinching sensation, skin sensitivity.

I have read the information regarding Emshape and understand the treatment risk and side effects.

PDO Threads
Threads are placed under the skin via needle in the lower part of the face, neck, jaw and jowls once a topical numbing cream is applied for your comfort. Made from polydioxanone (PDO), the threads eventually dissolve while stimulating collagen and elastin production, creating a tightening effect. Once the needle is removed the threads remain in place for up to six months and then slowly dissolve. The procedure is completed by a registered nurse. The procedure can take up to 3 months to be effective. The most common side effects associated with PDO Mono Threads but 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 include: Irreversible discoloration, Abscess (hard and swollen sore that may contain pus), Stroke, Exacerbate the asymmetry of the treated area, Generalised side effects may occur such as rash, Itchiness, allergic reactions, flu like symptoms, and hypertrophic scars/keloids and tightness.

I have read the information regarding PDO Mono threads and understand the treatment risk and side effects.

Full Name: (required)
Address: (required)
Date: (required)