Renuvion Consent Form

RENUVION 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: *

ONLY SIGN IF YOU FULLY AGREE AND UNDERSTAND

I authorise Dr. Glenn Murray to perform the proposed procedure listed below utilising Renuvion technology.

By initialling each section, you acknowledge you have read and understood the information provided to you:

The treatment will use a helium plasma device to deliver radiofrequency energy resulting in heat to the subdermal connective tissues for therapeutic purposes.

I fully understand and have been explained the procedure. I understand that the practice of medicine and surgery is not an exact science and that results may vary. While there may be some initial improvement, the full clinical results may not be apparent for approximately six to twelve months and no guarantees of my results have been given to me.

Possible outcomes - both short and long term

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)

Risks and possible complications

Although uncommon, I understand the following are possible complications and/or risks of this procedure: unintended burns, infection of incision sites, gas buildup resulting in temporary and transient crepitus or pain, temporary nerve injury, scars and death.

I may experience mild to moderate swelling post procedure that can potentially last a few days to a few weeks.

I understand that I may experience temporary discomfort during and post procedure.

It has been explained to me that there may be additional risks associated with the use of other products, technologies or procedures in conjunction with Renuvion.

I understand the importance of following the pre/post procedure instructions given to me by Dr. Murray and that failure to comply with all instructions may result in an unsatisfactory result and/or increase my risk of complications.

I understand that while the manufacturer does not list any declared contraindications for this procedure, Dr. Murray has reviewed my health history and advised me of any "cautions or warnings" that may be associated with radiofrequency energy based on my medical history.

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

The procedure, risks, ramifications, complications and alternative methods of treatment have fully been explained to me by my provider(s) and I have been given the opportunity to have my questions answered. My signature below acknowledges that I have been fully informed and that I consent to the procedure listed.

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.

INITIAL *

Agreement to treatment. *

Areas of treatment. *

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

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.

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

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

Doctor's Signature

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Date

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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