FAT TRANSFER 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.

FIRST NAME: *

LAST NAME: *

DATE OF BIRTH: *

WHAT IS FAT TRANSFER?

Fat transfer is a natural, long-lasting method of filling and supporting the face and/ or body using your own fatty tissue. The fat cells are gently placed at varying depths beneath the skin, creating an overall appearance of fullness.

This method allows your own tissue to be sculpted in a realistic, three-dimensional fashion. Because the grafted fat cells become integrated with the existing depleted tissue, it is very difficult to see or even feel the newly grafted cells aside from the overall improvement detectable by photography.

As we age or experience major fluctuations in weight, the shape and elasticity of our tissue changes and this will eventually affect the quality of your result. Nothing is completely permanent, but you can expect improvement that is usually long-lasting.

I fully understand this procedure

Possible outcomes - both short and long term

Risks specific to the patient - inclusive of the possible impact of comorbities/patient history (can affect results)

Anaesthesia includes:

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

INITIAL

Oral analgesia will be provided post operatively.

Recovery times and specific care requirements

Possibility of the need for revision procedure/s or further treatment - both short and long term (extra expense to the patient)

Fees from $2,200 for first procedure (one area)

From $660 for subsequent procedures “top ups”

Can be single or multiple procedure

Donor site(s) complications

Scars - incision sites

Allergies - including to skin preparation

Post-operative care complications

Follow-up appointment

Photos

Risks and Complications:

Pain

Swelling 1-6 weeks

Bruising - hematoma

Restricted activity 2-7 days

Scars

Final result - 6-12 weeks after last procedure

Under-correction

Over-correction (and weight gain) - less common

The infrequent and unexpected

Fat embolus

Reabsorption of graft - 50% survival rate variable

Complete reabsorption of graft - uncommon

Necrosis of graft

Discolouration of skin - uncommon

Prolonged redness of incision site - uncommon

Infection - uncommon

Blindness (Facial Procedures)

Tattooing - rare

Skin necrosis and damage to nerves, muscles, blood vessels and accessory structures.

Lumps, irregularities and asymmetry - uncommon

Stroke

Perforation - rare

Death

Pre- and post-operative photographs will be taken of the treatment site for record-keeping purposes. I understand that these photographs/videos will be the property of the Medical Director. Choose one:

I DOI DO NOT

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.

Please initial *

Agreement to treatment. INITIAL *

Your procedure will be performed at Suite 1/21 Stirling HWY, Nedlands, WA, 6009.

INITIAL

Areas of treatment

Patient/Substitute Decision Maker Full Name *

Patient/Substitute Decision Maker Signature *

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Date *

Consent needs to be signed at least 7 days prior to surgery.

INITIAL

A copy of the signed consent has been provided to me.

INITIAL

Witness Full Name *

Witness signature *

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Date *

I certify that I have discussed all the above with the patient and have answered all questions regarding the procedure. I believe that the patient fully understands what I have explained and answered.

Doctor’s Full Name

Date

Doctor’s Signature

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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)

Specific language services required

I declare that I have interpreted the dialogue between the patient/person(s) responsible and doctor/ healthcare provider to the best of my ability and have advised of any concerns about my interpreting of this dialogue.

Interpreter’s Full Name

Date

Interpreter’s Signature

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Agency name

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