Facial Consent Form


IMPORTANT INFORMATION:  Please read and complete  all sections of the consent forms electronically. Ensure a  witness (a friend or family member is acceptable)  is present to fill out their required sections  clearly and legibly. Confirm that  all fields, including the witness's details, are  completed prior to submission.

ONLY SIGN IF YOU FULLY AGREE AND UNDERSTAND

I

agree to undergo

Anaesthesia includes:

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

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

Risks and Complications that are possible include:


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. 

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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.

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Dr. Glenn Murray

Registered Medical Practitioner (MED0001196978) 

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


Interpreter’s Declaration (if applicable)

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.

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