Patient Consent Form — The Greville Clinic

I request and consent to the application of topical numbing gel by the treating registered nurse prior to my treatment.

I understand that topical numbing gel may not be suitable for individuals with known allergy or hypersensitivity to local anaesthetics, broken/infected skin, significant liver disease, methemoglobinemia, or any condition the practitioner deems inappropriate.

I understand that side effects may include redness, swelling, itching, blanching or irritation, and that rare complications may include systemic toxicity or severe allergic reactions.

I confirm that I have disclosed all known allergies, medical conditions, and current medications.

I understand that individual responses to topical numbing gel vary and no guarantee of effectiveness can be provided.

I have read, understood, and voluntarily consent to the application of topical numbing gel.

I confirm that the proposed treatment, including expected outcomes, risks, benefits, alternatives, and costs, has been explained to me.

I understand that cosmetic treatment results vary between individuals and no guarantee has been made regarding outcomes.

I have had the opportunity to ask questions and am satisfied with the information provided.

I understand that cosmetic procedures are generally not covered by Medicare.

I understand that my treatment plan may be adjusted on the day based on an assessment of my skin, anatomy, and aesthetic goals.

I voluntarily consent to proceed with treatment today.

I consent to photographs being taken for clinical assessment, treatment planning, monitoring outcomes, and medical record keeping.

I understand that these photographs will be stored securely in accordance with clinic privacy requirements.

I acknowledge that I have been directed to and had the opportunity to review The Greville Clinic Refund and Exchange Policy.