COSMETIC MODEL REGISTRATION

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All appointments made cannot be moved or rescheduled as they are part of a Training Academy with Set sessions. Do you understand?* This field is required.
Yes I understand I cannot move my appointment or cancel once booked.
No I need to have flexibility
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Your name* This field is required.
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Your Email Address* This field is required.
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Your Address* This field is required.
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Your date of birth* This field is required.
Date
Day
Month
Year
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Mobile Phone* This field is required.
Mobile Phone
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Emergency Name* This field is required.
First Name
Last Name
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Emergency Contact Phone* This field is required.
Mobile Phone
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MEDICAL HISTORY: Have you ever had any of the following?* This field is required.Please select all that apply
NONE
Anti-Wrinkle/Botox treatment
Dermal Filler treatment
Facial Surgery
Cold Sores
Rhinoplasty
Facelift (full or mini)
Skin cancer
Smoker
Rheumatic Fever
Heart Murmur
Heart Defect
High Blood Pressure
Diabetes
Pacemaker
Hip Replacement
Asthma
Stroke
Hepatitis
Osteoporosis
Bisphosphonates (eg. Prolia)
Keloid Scarring
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Please Confirm* This field is required.You cannot have treatment if you are having a baby. might be pregnant or are breastfeeding.
Yes, This is correct
I am not pregnant
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I am not trying to get pregnant
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I am not breastfeeding
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I am not pregnant
I am not trying to get pregnant
I am not breastfeeding
Yes, This is correct
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Yes, This is correct
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Yes, This is correct
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Are you taking any medication? This may include natural supplements* This field is required.
Yes
No
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Please list your medications, including supplements:
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Do you have any allergies?* This field is required.
Yes
No
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Please list your allergies:
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CONFIRMATION OF MEDICAL HISTORY: I HAVE PROVIDED ACCURATE INFORMATION ABOUT MYSELF. I understand failure to do so may compromise my health, and the treating practitioner may not provide treatment.* This field is required.SIGNATURE
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Rate your feelings about the following statements, without spending too much time* This field is required.
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
One the whole, I am happy with myself
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I feel distressed about my appearance
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I have a lot to be proud of
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I feel good about myself
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I avoid looking at myself
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One the whole, I am happy with myself
I feel distressed about my appearance
I have a lot to be proud of
I feel good about myself
I avoid looking at myself
Strongly agree
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What cosmetic procedures have you had in the last 12 months?* This field is required.
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IN THE NEXT SECTION, WE WILL NEED TWO PHOTOS OF YOU. USE THESE PHOTOS AS A GUIDE. DO NOT USE FILTERS.
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UPLOAD A PHOTO: FRONTAL (NO SMILE) - DO NOT USE FILTERS* This field is required.IF WE CANNOT SEE YOUR FACE CLEARLY, YOUR APPOINTMENT WILL NOT PROCEED
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Select files to upload
Max. file size: 10.6MB
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UPLOAD A PHOTO: FRONTAL (SMILING WITH TEETH!) - DO NOT USE FILTERS* This field is required.IF WE CANNOT SEE LINES, WRINKLES OR FOLDS IN THE PHOTOS, YOUR APPOINTMENT WILL NOT PROCEED
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Select files to upload
Max. file size: 10.6MB
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PHOTOGRAPHY CONSENT: Please read this consent carefully, before agreeing to proceed with treatment* This field is required.
I AGREE
1. Dermal Distinction Academy reproduces photographs and videos of patients for internal teaching purposes and for marketing material such as Facebook, Instagram, Vimeo and similar, in order to celebrate our practitioners and to advertise for upcoming courses.
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2. Dermal Distinction Academy may use and reproduce photographs, videos or images of you or your treatments for this purpose and is seeking your consent. Where possible, you will be de-identified with a bar across your eyes.
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3. Photographs that identify you are considered personal information. Dermal Distinction Academy will never release your name or medical history in association with these photographs or video. These are kept in accordance with the privacy act of Victoria.
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4. By agreeing to completing this form, I hereby agree to Dermal Distinction Training Academy using, reproducing and disclosing photographs and videos of me for use as internal teaching material or promotional marketing material.
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5. I understand that I can withdraw my consent to photos at any time by contacting Dermal Distinction Academy by email academy@dermaldistinction.com
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1. Dermal Distinction Academy reproduces photographs and videos of patients for internal teaching purposes and for marketing material such as Facebook, Instagram, Vimeo and similar, in order to celebrate our practitioners and to advertise for upcoming courses.
2. Dermal Distinction Academy may use and reproduce photographs, videos or images of you or your treatments for this purpose and is seeking your consent. Where possible, you will be de-identified with a bar across your eyes.
3. Photographs that identify you are considered personal information. Dermal Distinction Academy will never release your name or medical history in association with these photographs or video. These are kept in accordance with the privacy act of Victoria.
4. By agreeing to completing this form, I hereby agree to Dermal Distinction Training Academy using, reproducing and disclosing photographs and videos of me for use as internal teaching material or promotional marketing material.
5. I understand that I can withdraw my consent to photos at any time by contacting Dermal Distinction Academy by email academy@dermaldistinction.com
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I AGREE TO THE USE OF PHOTOS THAT I MAY APPEAR IN BY DERMAL DISTINCTION ACADEMY.* This field is required.SIGNATURE
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Let's make sure you are happy to be part of a group setting.

What does the training treatment involve?

Your practitioner has undertaken theoretical cosmetic injection training. Soon they are attending our Academy for a training day, and your practitioner has selected you to receive treatment under our guidance. Since each practitioner can select just one patient to treat, it is important that you understand what your treatment will involve so that the training day is what both you and your practitioner expect.

The training centre and treatment

Your treatment will be undertaken in a learning environment. This means multiple people will be present during your treatment. On the day, multiple practitioners will assess your face, and there will be multiple practitioners treating other patients too.

Support

We understand that having treatment can be daunting. However we cannot have additional people in the group training room as there is not enough capacity to accommodate them. If you feel that you cannot attend without a support person, please note that this is not the right setting for you.
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COSMETIC MODEL CONSENT: Please read this consent carefully, before agreeing to proceed with treatment* This field is required.
I AGREE
As a Cosmetic Model, there will be several people having treatment at one time, and multiple practitioners present. Are you happy to have treatment in a training session?
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As part of the Cosmetic Model treatment, your whole face will be assessed even if all areas are not treated. Are you prepared to be part of this?
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Cosmetic Models should desire several areas of their face to be treated with anti-wrinkle treatment. Are you willing to have several areas treated?
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Our trainers will make treatment recommendations to suit your face. Are you happy to be assessed and have recommendations made?
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I understand that the practitioner is undertaking supervised training, and is new or inexperienced to the cosmetic injector procedures
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I understand that should I require additional treatment or correction of treatment, I will be responsible for the cost of this.
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I agree to provide both my treating practitioner, Dr Giulia D’Anna and the team at Dermal Distinction Academy my medical history details so that I can undertake treatment.
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I understand that Follow-up treatment is not part of the Cosmetic model treatment. I will be given the details of my treating practitioner, or I can contact Dermal Distinction Academy for additional treatment. THIS WILL BE AT MY OWN EXPENSE.
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As a Cosmetic Model, there will be several people having treatment at one time, and multiple practitioners present. Are you happy to have treatment in a training session?
As part of the Cosmetic Model treatment, your whole face will be assessed even if all areas are not treated. Are you prepared to be part of this?
Cosmetic Models should desire several areas of their face to be treated with anti-wrinkle treatment. Are you willing to have several areas treated?
Our trainers will make treatment recommendations to suit your face. Are you happy to be assessed and have recommendations made?
I understand that the practitioner is undertaking supervised training, and is new or inexperienced to the cosmetic injector procedures
I understand that should I require additional treatment or correction of treatment, I will be responsible for the cost of this.
I agree to provide both my treating practitioner, Dr Giulia D’Anna and the team at Dermal Distinction Academy my medical history details so that I can undertake treatment.
I understand that Follow-up treatment is not part of the Cosmetic model treatment. I will be given the details of my treating practitioner, or I can contact Dermal Distinction Academy for additional treatment. THIS WILL BE AT MY OWN EXPENSE.
I AGREE
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I UNDERSTAND THAT I AM A COSMETIC MODEL IN A TRAINING ACADEMY. I agree to proceed.* This field is required.SIGNATURE
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IMPORTANT!! PLEASE WATCH THE VIDEO BELOW.

You cannot proceed without watching the video.
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DID YOU WATCH THE VIDEO IN THE LAST SLIDE?* This field is required.
YESNO
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What treatment are you interested in?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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THE PROCEDURE, OFF LABEL PRESCRIBING: Please read carefully, before agreeing to proceed with treatment* This field is required.
I UNDERSTAND
The muscle relaxant pharmaceuticals we use are made of purified protein that is suitable for therapeutic & cosmetic use.
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Our dermal fillers are made from Hyaluronic Acid, which over time will dissolve. All our pharmaceuticals are TGA listed.
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We regularly use them for off-label indications to achieve some results. This is where TGA has not evaluated the use of the pharmaceutical for all possible treatment areas, or for a different delivery method other than a needle. We regularly place muscle relaxants in off-label areas such as the jowls or lower face. We also regularly use a cannula for delivery of dermal filler to reduce treatment risks. These are known, studied and medically accepted standards of treatment. We will only use muscle relaxants and filler where required and is safe to do so.
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THE PROCEDURE IS: 1. Photographs will be taken before treatment. 2. When performing lip enhancement, dental anaesthesia will be given to make the procedure very comfortable. 3. Dermal filler will be injected into the target area. The results will be immediate but will improve over the next 2 weeks. 4. Anti-wrinkle treatment will be undertaken to minimize muscle activity in the target treatment areas. This takes 2-14 days to become fully effective. Subsequent treatments will be required to add to the effect, and to maintain it over the long term.
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Other options include: No treatment, Cosmetic Surgery, Skin treatment to improve skin elasticity. These are recommended to reduce the need for ongoing treatment and to help improve your results.
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The muscle relaxant pharmaceuticals we use are made of purified protein that is suitable for therapeutic & cosmetic use.
Our dermal fillers are made from Hyaluronic Acid, which over time will dissolve. All our pharmaceuticals are TGA listed.
We regularly use them for off-label indications to achieve some results. This is where TGA has not evaluated the use of the pharmaceutical for all possible treatment areas, or for a different delivery method other than a needle. We regularly place muscle relaxants in off-label areas such as the jowls or lower face. We also regularly use a cannula for delivery of dermal filler to reduce treatment risks. These are known, studied and medically accepted standards of treatment. We will only use muscle relaxants and filler where required and is safe to do so.
THE PROCEDURE IS: 1. Photographs will be taken before treatment. 2. When performing lip enhancement, dental anaesthesia will be given to make the procedure very comfortable. 3. Dermal filler will be injected into the target area. The results will be immediate but will improve over the next 2 weeks. 4. Anti-wrinkle treatment will be undertaken to minimize muscle activity in the target treatment areas. This takes 2-14 days to become fully effective. Subsequent treatments will be required to add to the effect, and to maintain it over the long term.
Other options include: No treatment, Cosmetic Surgery, Skin treatment to improve skin elasticity. These are recommended to reduce the need for ongoing treatment and to help improve your results.
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THE RISKS: By checking the boxes, you confirm that you understand the risks:* This field is required.
I UNDERSTAND
Injection-related reactions including: bruising, swelling, tenderness, headache, cold sore activation (in susceptible people).
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Swelling in dermal filler treatment areas may magnify the result, and can take around 2 days or more to settle down.
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All faces are not symmetrical and treatment cannot fully correct this. Our aim is to improve the curves, contour and your overall appearance, whilst still leaving you looking like you.
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Allergic reaction
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After BTX-A treatment, some people can have hearing or vision changes as nearby muscles react to treatment. This is temporary in nature.
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Blocked blood vessels (Also known as a vascular occlusion) can occur resulting in skin changes or damage, which may require that we dissolve the filler using an enzyme. You will need to allow us to perform this procedure for your safety and we will proceed as an emergency situation.
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Rarely we may need to make a referral to a vascular surgeon immediately.
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Very rarely (estimated at 0.001%), blindness and stroke has occurred from filler injections, where the filler enters the blood vessel and travels into the eye blood vessels. This will be treated, but may not be able to be reversed.
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If you experience increasing discomfort, skin colour changes or anything that you are not sure about, please email us on academy@dermaldistinction.com This email address is monitored and we will contact you to check how things are progressing.
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Injection-related reactions including: bruising, swelling, tenderness, headache, cold sore activation (in susceptible people).
Swelling in dermal filler treatment areas may magnify the result, and can take around 2 days or more to settle down.
All faces are not symmetrical and treatment cannot fully correct this. Our aim is to improve the curves, contour and your overall appearance, whilst still leaving you looking like you.
Allergic reaction
After BTX-A treatment, some people can have hearing or vision changes as nearby muscles react to treatment. This is temporary in nature.
Blocked blood vessels (Also known as a vascular occlusion) can occur resulting in skin changes or damage, which may require that we dissolve the filler using an enzyme. You will need to allow us to perform this procedure for your safety and we will proceed as an emergency situation.
Rarely we may need to make a referral to a vascular surgeon immediately.
Very rarely (estimated at 0.001%), blindness and stroke has occurred from filler injections, where the filler enters the blood vessel and travels into the eye blood vessels. This will be treated, but may not be able to be reversed.
If you experience increasing discomfort, skin colour changes or anything that you are not sure about, please email us on academy@dermaldistinction.com This email address is monitored and we will contact you to check how things are progressing.
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POST OPERATIVE INSTRUCTIONS: By checking the boxes, you confirm that you understand the AFTER-CARE INSTRUCTIONS:* This field is required.
I UNDERSTAND
After treatment, do not manipulate the area(s) treated.
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Heavy massage or pushing on the face/neck for 4 hours after botox treatment, and 7 days after dermal filler treatment should be avoided. This has the risk of moving the drug from the treated area, and the result may be changed. This includes avoiding facials, lymphatic drainage or other heavy massage of the treated area.
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Avoid dental procedures for 14 days after filler treatment to reduce the risk of bacterial infection from your own mouth.
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Use sunscreen and active skincare to improve results of treatment. Healthy and hydrated skin responds better.
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This procedure is an elective and rebates cannot be claimed.
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In the event of a complication, we expect you attend all follow up appointments, and also follow my direction to attend any referrals made to specialists or medical doctors that we recommend to you.
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I have had enough time to consider the information from my treating practitioner and feel that I am sufficiently advised to consent to this procedure.
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After treatment, do not manipulate the area(s) treated.
Heavy massage or pushing on the face/neck for 4 hours after botox treatment, and 7 days after dermal filler treatment should be avoided. This has the risk of moving the drug from the treated area, and the result may be changed. This includes avoiding facials, lymphatic drainage or other heavy massage of the treated area.
Avoid dental procedures for 14 days after filler treatment to reduce the risk of bacterial infection from your own mouth.
Use sunscreen and active skincare to improve results of treatment. Healthy and hydrated skin responds better.
This procedure is an elective and rebates cannot be claimed.
In the event of a complication, we expect you attend all follow up appointments, and also follow my direction to attend any referrals made to specialists or medical doctors that we recommend to you.
I have had enough time to consider the information from my treating practitioner and feel that I am sufficiently advised to consent to this procedure.
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I have read this informed consent and certify that I understand its contents in full. I agree to treatment and would like to go ahead. I understand that I can ask questions before my procedure on the day of treatment.* This field is required.SIGNATURE
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APPOINTMENTS AVAILABLE* This field is required.ONCE BOOKED: Appointments cannot be rescheduled or cancelled. Your booking fee will be forfeited. Booking fee includes assessment and all treatment that you require.
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ORDER SUMMARY
Total costAUD
Anti-Wrinkle: March 14th 1:00pmFull Face Anti-Wrinkle assessment and treatment.
$195AUDEdit
Back
Anti-Wrinkle: March 14th 1:30pmAnti-Wrinkle assessment and treatment.
$195AUDEdit
Back
Anti-Wrinkle: March 14th 2:30pmAnti-Wrinkle assessment and treatment.
$195AUDEdit
Back
Anti-Wrinkle: March 14th 3:00pmAnti-Wrinkle assessment and treatment.
$195AUDEdit
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TMJ / Face Slimming: March 18th 12:15pmTMJ / Face Slimming: assessment and treatment
$175AUDEdit
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Total cost $0.00AUD
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