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The Greville Clinic

Treatment Consent & Pricing Agreement

Please complete every section. Fields marked * are required.

Patient & appointment
Pricing summary
Leave blank if not applicable.
Important: Follow-up and review appointments may incur additional costs. Any product used during follow-up treatments will be charged at the clinic’s current pricing at the time of treatment.
Product breakdown
Product nameQuantityUnits / mlCost ($)
1 · Treatment cost

Please tick to confirm your understanding and consent.

2 · Consent for topical numbing gel

Select Yes if you agree. If No is selected for the first question, the remaining numbing gel consent questions are not required and will be hidden.

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

Contraindications. I understand that topical numbing gel may not be suitable for individuals with:

  • Known allergy or hypersensitivity to local anaesthetics (including lidocaine, prilocaine, tetracaine, benzocaine, or related compounds).
  • Previous allergic reactions to ingredients contained within the numbing gel.
  • Broken, infected, inflamed, or severely irritated skin at the intended application site.
  • Significant liver disease, methemoglobinemia, or other conditions affecting the metabolism of local anaesthetic agents.
  • Any condition that, in the opinion of the treating practitioner, makes topical anaesthetic use inappropriate or unsafe.

Potential risks and side effects. I understand that side effects may include redness, swelling, itching, blanching or irritation at the application site, and that rare complications may include:

  • Systemic absorption of the medication resulting in local anaesthetic toxicity, which may cause confusion, visual disturbances, ringing in the ears, tremors, seizures, cardiac irregularities, or other serious medical complications.
  • Severe allergic reactions (anaphylaxis) requiring urgent medical intervention.

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 that no guarantee of effectiveness can be provided.

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

3 · Cosmetic aesthetic treatment consent

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, as recommended by my practitioner.

I voluntarily consent to proceed with treatment today.

4 · Clinical photography consent

I consent to photographs being taken for:

  • Clinical assessment and treatment planning.
  • Monitoring treatment outcomes.
  • Medical record keeping requirements.

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

5 · Refund and exchange policy

I acknowledge that I have been directed to and had the opportunity to review The Greville Clinic’s Refund and Exchange Policy. I acknowledge receipt of this information.

Final consent declaration
By signing below, I confirm that:
  • I have read and understood this document.
  • The information provided to me has been explained to my satisfaction.
  • I have disclosed all relevant medical information.
  • I voluntarily consent to the treatment outlined above and, where selected, the application of topical numbing gel.
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A copy of this completed consent will be emailed to you and retained in your clinical record.

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Spring Gift Cards

Buy a $1000 gift card for $900, a $500 for $450, a $250 for $225 or a $150 for $135. Redeemable across all our treatments and skincare. Available until 30 September 2026.

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