Signing example
Sign a cosmetic procedure consent online
A cosmetic procedure consent has to prove the decision was not made in the consulting room: the referral, two consultations and a cooling off period come first, and the signature after. This three page consent for upper eyelid surgery prints the cooling off end date of 29 September 2026 on page 1, and the patient's stamped signature reads Oct 4, 2026.
The document, with its fields
The pages as a signer sees them, with the signature, name, title and date fields placed where each party has to complete them.
Consent for Cosmetic Surgery
1. Patient, surgeon and procedure
| Patient | Priyanka Sandhu, date of birth 30 January 1978 |
|---|---|
| Surgeon | Dr Felix Arnaud-Hale, specialist plastic surgeon, who performs the whole procedure himself |
| Procedure | Upper eyelid blepharoplasty, both eyes: removal of excess skin and a small amount of fat from the upper eyelids through a cut in the natural crease |
| Anaesthetic | Local anaesthetic with light sedation, given by a specialist anaesthetist |
| Where | Spring Hill Day Surgery, a licensed private facility |
| Planned date | Friday 16 October 2026 |
| Total fee | $7,450.00 including GST: surgeon $5,200, anaesthetist $1,100, facility $1,150. No Medicare rebate applies to a cosmetic procedure |
2. The steps before this consent
| Step | Date |
|---|---|
| GP referral received | 18 August 2026, from Dr Leah Coombes |
| First consultation with Dr Arnaud-Hale | 1 September 2026 |
| Second consultation, including photographs and the quote | 22 September 2026 |
| Cooling off period ends | 29 September 2026, seven days after the second consultation |
| Earliest date this consent may be signed | 30 September 2026 |
The cooling off period exists so the decision is not made in the consulting room. Lumen will not accept a signature on this consent dated on or before 29 September 2026, and no deposit is taken until the cooling off period has ended.
3. What results to expect
Upper eyelid surgery removes heavy or hooded skin so the eyelids look less tired. The final result settles over three to six months. Lumen does not promise a particular appearance, and computer images or photographs of other patients shown during consultation are illustrations only. The two eyelids will not be perfectly identical, and the scar, though hidden in the crease, is permanent.
4. Risks
| Risk | What it means |
|---|---|
| Swelling and bruising | Expected for one to two weeks. Sunglasses and cold packs help |
| Dry or watery eyes | Common for a few weeks; lubricating drops are supplied |
| Asymmetry | A small difference between the two sides; occasionally a revision is needed |
| Scarring | Usually a fine line in the crease, but some people form thicker or red scars |
| Difficulty closing the eyes | Uncommon, usually temporary. Rarely needs further surgery |
| Infection or bleeding | Uncommon. A collection of blood behind the eye is very rare but is an emergency |
| Change in vision | Blurred vision for a few days is common. Loss of vision is extremely rare |
| Dissatisfaction | The result may not match what you hoped for, even when the operation goes as planned |
5. Revision and costs
If Dr Arnaud-Hale recommends a revision within 12 months for asymmetry or excess skin left behind, his fee is waived; the anaesthetist and facility fees still apply. Fees are not refunded because the result is not what was hoped for.
6. Photographs
Photographs are taken before surgery and at follow up to plan the operation and record the result in your clinical file. Type an X in the box if you agree. Photographs are for your clinical record only: they are never used in advertising, on social media, on the website or for teaching, and no separate consent for that is asked for on this form.
| Agree | Statement |
|---|---|
| I agree to before and after photographs being taken and kept in my clinical record, for my care only. |
7. Cancelling
You may cancel at any time before surgery. The $1,000 deposit is refunded in full if you cancel more than 7 days before 16 October 2026, and $850 is refunded if you cancel later, the difference covering the anaesthetist's booking.
8. Before and after surgery
- Stop fish oil, vitamin E and anti-inflammatory medicines 10 days before surgery, after checking with your GP.
- Do not drive on the day. An adult must take you home and stay with you overnight.
- Sutures are removed on day 6 at the rooms. Avoid eye make-up for two weeks and swimming for three.
- Call the rooms on 07 3832 6640, or the after hours number 0400 551 902, for bleeding, rising pain or any change in vision.
9. Patient's statement
I confirm that I was referred by my GP, that I had two consultations with Dr Arnaud-Hale, the second on 22 September 2026, and that I have had at least seven days since then to think about my decision. I have read the risks on page 2, I understand the result cannot be guaranteed, and I know the total fee. I consent to upper eyelid blepharoplasty of both eyes as described on page 1. I understand I can withdraw this consent at any time before surgery.
10. Surgeon's statement
I have assessed the patient, discussed her reasons for surgery and her expectations, explained the procedure, alternatives including no surgery, the risks and the costs, and I believe she understands them and is a suitable candidate.
11. Your follow up appointments
| Appointment | When |
|---|---|
| Suture removal and wound check | Thursday 22 October 2026, with the practice nurse |
| Review with Dr Arnaud-Hale | Six weeks after surgery |
| Final review and photographs | Six months after surgery |
Who signs what
- Priyanka Sandhu, patient
- Initials on page 1 and page 2 · An X agreeing to photographs for her clinical record only · Signature and stamped date on page 3, after the cooling off period · Verified by an emailed six digit code
- Dr Felix Arnaud-Hale, surgeon
- Signature block on page 3: Name, Title and a stamped Date · Email link
The signing journey
Step 1
Sent after the cooling off period
The clinic sends the envelope once 29 September 2026 has passed, and the message says so, so the earliest possible signature already falls on the right side of the date.
Step 2
A code from her own inbox
Her link opens a verification card. The six digit code lasts ten minutes and works once.
Step 3
Initials on the dates and the risks
Her drawing fills the initials under the expected results on page 1 and under the risks, revision and photographs on page 2.
Step 4
A separate photographs choice
The box is optional. She types an X to allow before and after photographs for her clinical record only.
Step 5
Her signature, then the surgeon's
Her date is stamped Oct 4, 2026. The surgeon's invitation follows, and he types Specialist Plastic Surgeon as his title.
Every field, and who fills it
Priyanka Sandhu initials at the bottom right of page 1 and page 2, types an X in the photographs box on page 2, and signs on page 3 under the patient's statement, where the caption reads Date signed, after 29 September 2026. Dr Felix Arnaud-Hale's block sits beside hers, headed Surgeon. The $7,450 total, the surgeon, anaesthetist and facility fees, the 16 October 2026 surgery date and the $1,000 deposit terms are printed.
How to adapt this envelope
A clinic offering a minor procedure such as injectables can keep the same three page shape, replace the referral and consultation dates with its own pre treatment steps, and keep the photographs box. Where the anaesthetist also needs a signed consent, that is a separate envelope with the anaesthetist as the countersigning recipient. A patient under 18 needs different handling entirely, and this form should not be used.
What makes this valid in Australia
The Electronic Transactions Act 1999 recognises an electronic signature that identifies the signer and shows intention, by a reliable method. The Medical Board of Australia's guidelines for cosmetic surgery and procedures set expectations on referral, consultations, cooling off and consent, which the steps on page 1 record. A signature does not replace the consultations; it records the decision made after them.
What makes this signing flow work
The date can be checked against the page
Page 1 prints the cooling off end date and the earliest date the consent may be signed. The stamped date under her signature is drawn by the product from the moment she finished, not typed, so anyone can compare the two on the finished PDF.
Initials on the two pages that change minds
Page 1 says what results to expect and that no appearance is promised; page 2 lists the risks and the fee terms. Her initials on both show she had them in front of her, and page 3 carries her signature.
Photographs as their own decision
The photographs statement limits use to her clinical record and is a separate optional box. Saying yes to surgery does not mean saying yes to photographs, and the form records each on its own.
Questions people ask
Can a cosmetic surgery consent be signed before the cooling off period ends?
This clinic will not accept one dated on or before 29 September 2026, and sends the envelope only after that date. Because the stamped date comes from the moment of signing and cannot be typed, a signature from inside the cooling off period would show on the page.
Why is the patient verified with a code?
The consent records a personal medical decision and a payment of $7,450. A six digit code sent to her own inbox means the person who opened and signed the consent controls that email address, and the certificate records the method beside her name.
Can the clinic use the before and after photographs in advertising?
Not under this form. The statement she marked limits the photographs to her clinical record, and the form says they are never used in advertising, on social media or for teaching, and that no separate consent for that is asked for on this form.
What does the certificate show about when she signed?
The UTC time she signed and the time she accepted the electronic signing consent, with her IP address and the hash of the document. Together with the stamped date on page 3, it shows the consent was given on 4 October 2026, after the printed cooling off date.
Can she change her mind after signing?
Yes. Clause 9 says she may withdraw consent at any time before surgery, and clause 7 sets out the deposit refund. The certified PDF cannot be altered, so withdrawal is recorded by telling the clinic, not by editing the signed consent.
What happens if she declines the envelope?
The envelope moves to declined and the clinic is emailed with any reason she typed. The surgeon is never invited and no consent exists, so the surgery does not go ahead on 16 October unless a new consent is signed.
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