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Important Notice

SUPREME COURT OF NEW SOUTH WALES

RICKHUSS & ORS

v

THE COSMETIC INSTITUTE PTY LIMITED & ORS

(2017 / 279308)

IMPORTANT NOTICE

REPRESENTATIVE ACTION CONCERNING BREAST AUGMENTATION SURGERY PERFORMED ON PATIENTS OF THE COSMETIC INSTITUTE

REGISTRATION REQUIRED FOR PARTICIPATION IN SETTLEMENT AND FURTHER OPPORTUNITY TO OPT OUT OF THE PROCEEDING

On 14 September 2017 proceedings were commenced in the Supreme Court of New South Wales against a number of defendants. The lead plaintiffs who are bringing the proceedings are Ms Rickhuss, Ms Pollock, Ms Bruen, Ms Rowlands, Ms Knowland, Ms Rutherford, Ms Axen, Ms Zahr, Ms Love, Ms Gielisse, Ms Turner and Ms Sanchez (plaintiffs). The first four defendants are The Cosmetic Institute Pty Limited (in liquidation), TCI Bondi Pty Limited (in liquidation), The Cosmetic Institute Parramatta Pty Limited (in liquidation) and TCI Southport Pty Limited (in liquidation) (TCI companies). The fifth defendant is a plastic surgeon, Dr Eddy Dona. The defendants who performed surgery at the TCI companies are Dr Eddy Dona, Dr Niroshan Sivathasan, Dr Van Huu Anthony Nguyen, Dr Victor Lee, Dr Chi-Vien Duong (aka Charles Wong), Dr Anh Huy Tang, Napoleon Po-Han Chiu, Dr Daniel Kwok, Dr Pedro Miguel da Silva Valente, Dr Farheen Ali, Dr James Francis Christopher Kenny, Dr Sri Balakrishnan Darshn (doctor defendants). The remaining defendants are Certain underwriters at Lloyd’s subscribing to policy no. 04012, Allied World Assurance Company Ltd and MDA National Insurance Pty Ltd (insurer defendants).

The proceedings concern allegations about breast augmentation surgery performed at the TCI companies’ premises or by the doctor defendants engaged and trained by the TCI companies and Dr Eddy Dona (TCI Representative Action). Persons on whose behalf the proceeding has been brought are defined as “group members”.

The allegations are explained in more detail in section 2 of this notice. Section 3 describes who is a group member in the proceeding.

The Supreme Court has ordered that this notice be published for the information of persons who might be group members on whose behalf this representative action is brought and who may be affected by it.

If you think you may be a group member you should read this notice carefully as it may affect your rights. Any questions you have concerning the matters contained in this notice should not be directed to the Court. If there is anything in it that you do not understand, you should seek legal advice.

1. What is a representative proceeding?

A representative proceeding is commonly known as a class action. It is an action that is brought by the plaintiffs on their own behalf and on behalf of group members against the defendants, where the plaintiffs and the group members have similar claims against the defendants.

Group members are bound by any judgment or settlement entered into in the representative proceeding unless they choose not to participate by “opting out” of the proceeding or an order is made that group members who have not registered are not permitted to receive any settlement amount. This means that:

  1. if the representative action is successful or settles, group members may be eligible for a share of any settlement monies or Court-awarded damages;
  2. if the representative action is unsuccessful, group members are bound by that result; and
  3. regardless of the outcome of the representative action, group members will not be able to pursue their claims against the defendants in separate legal proceedings unless they have opted out.

2. What is the TCI Representative Action?

The TCI Representative Action is brought by each of the plaintiffs on their own behalf and on behalf of all persons who are group members as defined in the proceeding.

The plaintiffs claim that in and from 2012, the TCI companies and Dr Dona devised and implemented a system of breast augmentation surgery from facilities in New South Wales, and later, from a facility in Southport, Queensland. The plaintiffs in the TCI Representative Action allege that the TCI companies and Dr Dona were negligent in the design, implementation, performance and marketing of their system of breast augmentation surgery, including the anaesthesia under which the surgery was performed. The plaintiffs also allege that the defendants’ system of breast augmentation surgery performed by the surgical defendants was unsafe and not fit for purpose in contravention of the Australian Consumer Law.

The plaintiffs claim that they and group members have suffered personal injury, loss and damage as a result of undergoing breast augmentation surgery at the defendants’ premises or by the surgical defendants. They claim that their injury, loss and damage were caused by the defendants’ negligence and contravention of the Australian Consumer Law and that they are therefore entitled to damages.

The group members also include any “legal personal representatives” of the estates of any deceased person who would otherwise have qualified as a group member.

The plaintiffs’ allegations made on their own behalf and on behalf of group members are detailed in the Fourth Further Amended Statement of Claim filed 31 May 2022. The first to fourth defendants are not defending the allegations in the representative action. No insurer has agreed to indemnify the first to fourth defendants. The fifth defendant denies the allegations and is defending the representative action, as are the surgical defendants and the insurer defendants.

3.   Are you a group member?

Group members are persons who at any time before 15 September 2017:

  1. had breast augmentation surgery performed by a surgical defendant at TCI Parramatta, TCI Bondi Junction, TCI Southport, Concord Private Hospital or Holroyd Private Hospital; AND,
  2. suffered injury as a result of the said breast augmentation surgery, whether it be physical or psychological injury; OR
  3. are the legal personal representative of the estates of any deceased persons described in (1) AND (2) above.

4.   What is opt-out?

The plaintiffs in representative proceedings do not need to seek the consent of group members to commence a representative proceeding on their behalf. However, group members can cease to be group members by “opting out” of the representative proceedings. If you have been included as a group member in the TCI Representative Action but you do not want to continue to be a group member, you must opt out now.

5.    Order concerning settlement and registration for settlement

The parties to the proceeding will be engaging in a mediation to see if the proceedings can be resolved this year prior to the matter proceeding to hearing. The hearing is presently set down to commence on 4 September 2023.

Settlement is unlikely to occur without greater certainty about the number of group members. Registration in accordance with this notice will enable the parties to have greater certainty about the number of group members, which will in turn make settlement more likely.

If the proceedings settle prior to the hearing, the plaintiffs will then make an application to the Court for approval of the proposed settlement. At that time, the plaintiffs intend to seek an order from the Court that, if it approves the settlement, the proceedings no longer continue as a representative proceeding. If the court makes that order, any group member who has not registered (explained below) by the date of the application to approve the proposed settlement or has not opted out of the proceeding will cease being a group member and shall not, without applying for and obtaining leave of the Court, be permitted to obtain any benefit from the settlement.

It will also mean that any person who has not registered in accordance with this notice will have to commence their own proceedings to seek any compensation based on their individual claim. It will also mean that the running of the limitation period for the remaining group members’ individual claims may be affected (addressed below under Limitation Period).

If you wish to register so that you can obtain the benefit of any settlement reached in the proceeding before final judgment, then you must register in accordance with this notice. If you do not register, you do not cease to be a group member. However, if (1) you have not registered for settlement by the date specified below (2) the proceedings settle and (3) the plaintiffs do seek and obtain approval of the settlement from the Court, you will be prevented from obtaining any benefit from the settlement unless you make an application to the Court seeking leave to participate in the settlement, and the Court grants that leave.

If you register after the date of the mediation, but prior to the date of the application to approve the settlement:

a. the prospects of approval of the settlement may be adversely affected as the proposed settlement may be refused;

b. the amount of any compensation you may receive could be adversely affected.

6.   What should group members do?

If you have already opted out, then you do not need to do anything.

If you have already completed the questionnaire annexed to this Notice to the best of your ability and provided it the plaintiffs’ solicitors, Turner Freeman Lawyers, then you do not need to do anything.

If you do not know if you have completed the questionnaire annexed to this Notice and you wish to do so, you should contact Turner Freeman Lawyers.

If you fit the definition of a “group member” in the representative proceeding and you have not previously opted out or completed the questionnaire annexed to this Notice, then the following three options are available to you:

Option 1:   Do Nothing

If you do nothing, you will remain a group member and remain bound by any order or judgment in the representative proceeding. The plaintiffs will continue to bring the proceeding on your behalf up to the point where the Court determines the questions that are common to the claims of the plaintiffs and the group members. However, if the proceeding settles and the Court makes an order that only those who registered for settlement are entitled to obtain the benefit of any settlement reached, then you will not (subject to you applying to the Court for leave, and obtaining a grant of leave) be entitled to any benefit obtained from settlement of the proceeding. If the settlement is approved by the Court, the representative proceeding will be ended (if the Court is minded to make such an order) and you will have to commence your own proceeding to seek compensation for any injuries you may have suffered. In that event, your right to compensation may be affected by the limitation period relevant to your claim (addressed below under Limitation Period).

Option 2:   Register for Settlement

If you wish to register for settlement, you should complete the “Registration for Settlement Notice” and questionnaire below to the best of your ability.

If you wish to help settle this action you should register for settlement before the deadline for mediation on 14 April 2023. In order to help achieve the most favourable settlement and to bring these proceedings to an end, you should return your “Registration for Settlement” form and questionnaire to Turner Freeman Lawyers so that it arrives before that deadline.

Although you may register at any time up to the date set by the Court for approval of any settlement reached, the prospects of any settlement being approved may be adversely affected as may the amount you may recover.

You will not be able to register after the date set by the Court to approve settlement.

Option 3:   Opt Out

If you do not wish to be a group member you should opt out of the proceeding by completing the “Opt Out Notice” below. If you opt out then you will cease to be a group member and will not be affected by any orders or settlement in the representative proceeding.

If you wish to bring your own claim against the defendants, you should seek your own legal advice about your claim and the applicable time limit before opting out (as a group member s 182 of the Civil Procedure Act 2005 (NSW) suspends the running of any limitation period that may apply to your claim that relates to the proceedings. Once you cease being a group member the running of the limitation period ceases to be suspended and continues to run).

If you wish to opt out, you should do so as soon as possible but you must do so before 14 April 2023. To opt you, send your “Opt Out Notice” to either the Supreme Court of NSW or Turner Freeman Lawyers so that it arrives before 14 April 2023.

7.   Will you be liable for legal costs?

Group members will not become liable for any legal costs simply by remaining or registering as group members. Group members in a representative action are not legally liable for the legal costs associated with bringing the proceedings but may in some circumstances be called upon to contribute a sum by way of security for legal costs of the defendants.

However, if the proceedings are successful and there is a judgment or settlement that results in compensation becoming payable to registered group members, then:

(a)   If the preparation or finalisation of your personal claim requires work to be done in relation to issues that are specific to your claim, you can engage Turner Freeman Lawyers or other solicitors to do that work for you. You may be liable for costs associated with the determination of issues concerned only with your claim;

(b)   If any compensation becomes payable to you as a result of any order, judgment or settlement in the representative proceeding, the Court may make an order that some of that compensation be used to help pay a share of the costs which are incurred by the plaintiffs in running the representative proceeding but which are not able to be recovered from the The plaintiffs will ask the Court to make such an order if the occasion arises; and

(c)   Representative proceedings are often settled out of Court. If this occurs in this proceeding, you may be able to claim from the settlement amount without retaining a lawyer (but you should register for settlement as outlined above).

8.   Limitation Period

Limitation periods are set by statute. If a person with an entitlement to a claim does not commence legal proceedings by the time a limitation period expires, they may be barred from making a claim.

The commencement of this representative action suspended the limitation periods for all group members who have not opted out at the date each respective defendant was joined to the proceeding. Time starts to run again for any related claim against the respective defendants once a person opts out of the representative action or the representative proceeding is ended. If you opt out of the representative action (or the representative proceeding is ended) and the statutory time limit on your claim expires, or is found to have already expired because you are no longer covered by the representative action, you will be barred from bringing proceedings against the applicable defendants in court. This will depend on your particular individual circumstances. If you register to participate in any settlement of the proceeding and the settlement is approved by the Court, you will not be able to pursue your individual claim and so no issue with the limitation period will arise.

Again, if you wish to bring your own claim against the defendants in court, you should seek your own legal advice about your claim and the applicable time limit.

9.   Where can you obtain further information, including copies of relevant documents?

Copies of relevant documents may be obtained by:

(a) telephoning Turner Freeman Lawyers on (02) 8222 3333  and requesting a copy to be posted;

(b) by downloading a copy from the Turner Freeman Lawyers website: https://www.turnerfreeman.com.au/

(c) inspecting a copy of the Statement of Claim by visiting the Registry of the Supreme Court in Sydney at Level 5, Law Courts Building, Queens Square, 184 Phillip Street, Sydney NSW;

(d) by downloading a copy from the Supreme Court website: http://www.supremecourt.justice.nsw.gov.au/Pages/sco2_classaction/The-Cosmetic-Institute-Class-Action.aspx

Please consider the above matters carefully. If you are not sure whether you are a group member or want further information, you can contact the plaintiffs’ solicitors, Turner Freeman Lawyers on (02) 8222 3333, or on the website (https://www.turnerfreeman.com.au/class-actions/the-cosmetic-institute-class-action/). You can also seek your own legal advice.

This notice is published pursuant to Orders made by the Supreme Court on 10 March 2023.


OPT OUT NOTICE

COURT DETAILS
Court Supreme Court of New South Wales
Division Common Law
List Professional Negligence
Registry Sydney
Case number 2017/279308
TITLE OF PROCEEDINGS
First plaintiff Amy Rickhuss
Number of plaintiffs 12
First defendant The Cosmetic Institute Pty Ltd (In Liquidation)
Number of defendants 19
FILING DETAILS
Filed for                                    , person opting out of representative proceedings
Legal representative
Legal representative reference
Contact name and telephone
Contact email
OPT OUT NOTICE
Name of person opting out
Address of person opting out

I, ……………………………, a group member in this representative proceeding, opt out of the proceeding.

I understand that in opting out:

  1. I forego the right to share in any relief obtained by the representative parties in the representative proceeding;
  2. I am not entitled to receive any further notification about the conduct or disposition of the proceeding; and
  3. To the extent that I have a claim against the defendants, any limitation period suspended by the commencement of the representative proceeding, has recommenced running.
SIGNATURE
Signature of or on behalf of
person opting out
Capacity
Date of signature
NOTICE TO PERSON OPTING OUT

You must, within the time specified in the notice to group members do either of the following:

1. File this form in the registry of the court at the address below, or in the manner provided in the notice to group members and serve a copy of this form on the representative party (Turner Freeman Lawyers) at the address, or in the manner provided, in the notice to group members.

OR

2.Complete this form and email a copy of it to Sally.Gleeson@turnerfreeman.com.au and request in your email that Turner Freeman Lawyers file this form in the court on your behalf. Turner Freeman Lawyers will file your form and confirm by email to you that the form has been filed within three business days of receiving your email. If you do not receive a confirmation email from Turner Freeman Lawyers that this form has been filed for you, please call Sally Gleeson at Turner Freeman Lawyers on (02) 8222 3333.

REGISTRY ADDRESS
Street address Supreme Court of NSW

Law Courts Building, Queen’s Square

184 Phillip Street

Sydney   NSW   2000

Postal address Supreme Court of NSW

GPO Box 3

Sydney   NSW   2000

Telephone 1300 679 272

 


REGISTRATION FOR SETTLEMENT NOTICE

COURT DETAILS
Court Supreme Court of New South Wales
Division Common Law
List Professional Negligence
Registry Sydney
Case number 2017/279308
TITLE OF PROCEEDINGS
First plaintiff Amy Rickhuss
Number of plaintiffs 12
First defendant The Cosmetic Institute Pty Ltd (In Liquidation)
Number of defendants 19
FILING DETAILS
Filed for                                    , person opting out of representative proceedings
Legal representative
Legal representative reference
Contact name and telephone
Contact email
REGISTRATION FOR SETTLEMENT NOTICE
Name of person opting out
Address of person opting out

I, ……………………………, a group member in this representative proceeding:

  1. wish to register for settlement so that I may receive any benefit obtained from the proceeding.
  2. have completed the attached Questionnaire to the best of my ability and enclosed any relevant photographs, medical records, or other evidence available to me.
  3. have read, and understand, the content of the Notice and the consequences of registration.
SIGNATURE
Signature of or on behalf of
person registering
Capacity
Date of signature
NOTICE TO PERSON REGISTERING FOR SETTLEMENT

You must, within the time specified in the notice to group members do the following:

1.Complete this form and email a copy of it to Sally.Gleeson@turnerfreeman.com.au. Turner Freeman Lawyers will confirm by email to you that the form has been received within three business days of receiving your email. If you do not receive a confirmation email from Turner Freeman Lawyers, please call Sally Gleeson at Turner Freeman Lawyers on (02) 8222 3333.

 


IN THE SUPREME COURT OF NEW SOUTH WALES

Case number: 2017/279308

Amy Rickhuss & Others v The Cosmetic Institute Pty Ltd, Dr Eddy Dona & others

QUESTIONNAIRE

 

DATE this form was completed:

………………………………..…………………………………………………………………………………………………………………………………………………

PERSONAL DETAILS

Salutation (Ms / Miss / Mrs / Dr / Other)

………………………………..…………………………………………………………………………………………………………………………………………………

Name

………………………………..…………………………………………………………………………………………………………………………………………………

Address

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………………………………..…………………………………………………………………………………………………………………………………………………

Date of Birth (dd/mm/yyyy)

………………………………..…………………………………………………………………………………………………………………………………………………

Email

………………………………..…………………………………………………………………………………………………………………………………………………

If you are unable to complete any part of this section of the form because you do not know the answers to the questions, you may seek advice from your treating doctor.

 

TCI – DESIRED RESULTS

What results did you want from your breast augmentation surgery?

□ Larger breasts
……………………………………………………………………………………………………………
□ Improve the aesthetic appearance of your breasts (to look better)

……………………………………………………………………………………………………………
□ Restore your breasts after pregnancy, breast feeding, aging or other conditions?

……………………………………………………………………………………………………………
□ Improve your self-esteem/ confidence

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□ Other reasons (please specify)

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PRIOR BREAST AUGMENTATION SURGERY

Was your breast augmentation surgery with TCI the first breast augmentation surgery you have had?

□ Yes.
□ No. If not please write below:

– The date of each breast augmentation surgery you had before your surgery with TCI
– The name of the surgeon who performed your breast augmentation surgery.
– Where the surgery was performed.
– The reason/s why you had this surgery.
– Whether it related to the left, right or both breasts.

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FIRST TCI BREAST AUGMENTATION SURGERY

Date of first TCI breast augmentation surgery:

……………………………………………………………………………………………………………

TCI Surgeon who you consulted with before the surgery:

……………………………………………………………………………………………………………

TCI surgeon who performed your surgery:

……………………………………………………………………………………………………………

TCI anaesthetist involved in your breast augmentation surgery:

……………………………………………………………………………………………………………

Place of first breast augmentation surgery (please tick):

□ TCI Parramatta
□ TCI Bondi
□ TCI Southport
□ TCI Parramatta Premises
□ Concord Private Hospital
□ Holroyd Private Hospital
□ Do not know

Type of breast implants inserted:

□ Round implants – tick if you had round implants
□ Other implants – please specify shape of implants
□ Do not know
……………………………………………………………………………………………………

Brand of implants

□ Allergan implants – tick if you had round implants
□ Other implants – please specify brand of implants

……………………………………………………………………………………………………

……………………………………………………………………………………………………

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Placement of implants

□ Subpectoral placement (under the muscle)
□ Subglandular placement (over the muscle)
□ Dual plane (partly under and partly over the muscle)
□ Do not know

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Did your TCI surgeon advise you that you may need a mastopexy or a breast lift before your first breast augmentation surgery with TCI? (Please tick)

□ No
□ Yes
□ Do not recall
□ Do not know

If yes:
Did you sign a form to say that although you understood that suboptimal results will only be achieved with your breast augmentation surgery, you wanted to have it anyway?
□ No
□ Yes

Prior to the breast augmentation surgery, did TCI refer you to Dr Eddy Dona to discuss having a mastopexy or breast lift performed by him?

□ No
□ Yes
□ Do not recall
□ Do not know

Prior to the breast augmentation surgery, did TCI offer to refer you to Dr Eddy Dona to discuss having a mastopexy or breast lift performed by him and you declined this offer?

□ No
□ Yes
□ Do not recall
□ Do not know

If yes, please advise your reasons.
………………………………………………………………………………
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FURTHER TCI BREAST SURGERY
Please ONLY complete this section below if you have had more than one breast surgery with TCI. This surgery includes further augmentation surgery, removal of implants, debridement, wash out, drainage of haematomas or infections.

Second breast surgery with TCI (only complete this if you have undergone such a surgery with TCI):

Date of surgery:
………………………………………………………………………………………………………………………………………………………………
Name of surgeon:
………………………………………………………………………………………………………………………………………………………………
Place of surgery:
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Reason/s for having this surgery (for example, infection, ruptured implant, to correct the cosmetic outcome from your surgery with TCI):
………………………………………………………………………………………………………………………………………………………………
Details of what surgery was performed and if it related to the left/right or both breasts:
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Details of what implant/s were used:
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Third breast surgery with TCI (only complete this if you have undergone such a surgery with TCI):

Date of surgery:
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Name of surgeon:
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Place of surgery:
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Reason/s for having this surgery (for example, infection, ruptured implant, to correct the cosmetic outcome from your surgery with TCI):
………………………………………………………………………………………………………………………………………………………………
Details of what surgery was performed and if it related to the left/right or both breasts:
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Details of what implant/s were used:
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Fourth or more breast surgery with TCI: If you have had four or more breast surgeries with TCI please write details in relation to each surgery below (as you did with the previous breast surgeries i.e. write the date of the surgery, who performed it, place where it was performed, reason/s for having the surgery, details of the surgery and implant/s used):

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INDEPENDENT BREAST SURGERY – not related to TCI
This surgery includes further augmentation surgery, removal of implants, debridement, wash out, drainage of haematomas, or infections.

After any breast augmentation surgery with TCI, have you had further breast surgery, which was NOT performed with TCI? This can include surgery performed by Dr Eddy Dona through his private practice.

□ No. (If no, you do not have to complete the details below).
□ Yes. (If so, please complete the details below)

First independent breast surgery unrelated to TCI (only complete this if you have undergone such a surgery):

Date of surgery:
………………………………………………………………………………………………………………………………………………………………
Name of surgeon:
………………………………………………………………………………………………………………………………………………………………
Place of surgery:
………………………………………………………………………………………………………………………………………………………………
Reason/s for having this surgery (for example, infection, ruptured implant, to correct the cosmetic outcome from your surgery with TCI):
………………………………………………………………………………………………………………………………………………………………
Details of what surgery was performed and if it related to the left/right or both breasts:
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
Details of what implant/s were used:
………………………………………………………………………………………………………………………………………………………………

Second independent breast surgery unrelated to TCI (only complete this if you have undergone such a surgery):

Date of surgery:
………………………………………………………………………………………………………………………………………………………………
Name of surgeon:
………………………………………………………………………………………………………………………………………………………………
Place of surgery:
………………………………………………………………………………………………………………………………………………………………
Reason/s for having this surgery (for example, infection, ruptured implant, to correct the cosmetic outcome from your surgery with TCI):
………………………………………………………………………………………………………………………………………………………………
Details of what surgery was performed and if it related to the left/right or both breasts:
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
Details of what implant/s were used:
………………………………………………………………………………………………………………………………………………………………

Third or more independent breast surgery: If you have had three or more independent breast surgeries unrelated to TCI please provide details of each surgery below (as you did with the previous independent surgeries i.e. write the date of the surgery, who performed it, place where it was performed, reason/s for having the surgery, details of the surgery and implant/s used):

………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………

COMPLICATIONS (INJURIES)

Please note that being unhappy with the staff or service provided by TCI (such as being rushed out after the surgery) is not a “Complication”. Please provide details of complications, which are injuries (physical or psychological). Some examples of Complications from breast augmentation surgery are outlined below. Please tick “yes” or “no” and complete the details requested in relation to each complication below.

Have you experienced any of the following after any of your breast augmentation surgeries with TCI?

If you are suffering with a psychological/psychiatric condition, had you ever suffered these symptoms before you had breast implants? If yes, for what period of time had you had the symptoms before the implants?
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If you had previously suffered with a psychological/psychiatric condition, had you ever required treatment before you had the breast implants? If so, what treatment did you have (e.g. seeing your GP, Psychologist, or Psychiatrist, and/or being prescribed medication) and for how long?
………………………………………………………………………………………………………………………………………………………………
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If you had previously suffered with a psychological/psychiatric condition, for which you have required treatment before you had breast implants, provide the name/s, specialty and address of the doctor/s you had treatment with.
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(Please provide details of where the pain is):
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AESTHETIC OUTCOME
Are you happy with how your breasts look? If not, please provide details of what you are not happy with.
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OTHER COMPLICATION/ INJURY
Please write details of any complication/ injury you have suffered as a result of your breast augmentation surgery with The Cosmetic Institute, other than the complications referred to in the above table. Please include the name/s, specialty and address of any doctors from whom you have sought treatment for those condition/s.

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CURRENT LEVEL OF PAIN
If you experience pain as a complication of your breast augmentation surgery, please rate your pain at its worst in the last week by circling the appropriate number below on a scale of 0 to 10, with 0 being no pain and 10 being the worst imaginable pain.

       0          1           2         3         4         5         6         7         8          9         10
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CURRENT SEVERITY OF SYMPTOMS
If you were to spend the rest of your life with your symptoms just the way they are now, how would you feel about that?

      0          1           2         3         4         5         6         7         8          9         10
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Pleased                              Indifferent                                   Terrible

If you have experienced pain of any level in the past week, how frequently do you experience that level of pain (eg every day, some days, occasionally etc).

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ACTIVITIES OF DAILY LIVING
Some women find that complications from their breast augmentation surgery affect their activities, relationships, and feelings (e.g. pain). For each question, check the response that best describes how much your activities, relationships or feelings have been affected by the complications you have suffered. Please tick the box that best describes the impact of the complications over the last 3 months. Please make sure you mark an answer in all 3 columns for each question.

CARE AND ASSISTANCE
Have you required assistance with the activities of daily living (outlined above) i.e. washing, cleaning, showering, preparation of meals, gardening and has that assistance been provided by an external provider, or a friend or member of your family, as a result of the complications you have suffered from the breast augmentation surgery?

□ Yes
□ No

If yes:

PAYMENT OF YOUR TREATMENT AND REHABILITATION EXPENSES
In answering the following questions, please consider any expenses associated with your breast augmentation surgery with TCI including the costs of revision surgery, consultations with your surgeon or another doctor, medical investigations (such as, x-rays, MRIs or other scans), medication (including Panadol and over the counter medication), consultations with a psychiatrist or psychologist.


Have any of your treatment expenses been reimbursed or paid directly by a private health insurer?

□ Yes. If so, please provide the name of your private health insurer and membership number:
…………………………………………………………………………………………………………………………………….
□ No

Medicare

Have any of your treatment expenses been reimbursed or paid directly by Medicare or any other government organisation (such as the Department of Veterans Affairs).

□ No

□ Yes – Medicare. Please provide your Medicare number:
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□ Yes – other government organisation. Please provide your details:
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First breast augmentation surgery with TCI
Please provide an estimate of the cost of your first breast augmentation surgery with TCI:

□ $5,990 including GST
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□ Other amount. Please specify: $
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Out of pocket expenses (other than the initial cost of your first breast augmentation surgery with TCI)

Are you out of pocket in relation to any treatment and rehabilitation expenses? In other words, have you paid any expenses that have not be covered by a private health insurer, Medicare or other government organisation? Please do not include the cost of your first breast augmentation surgery with TCI in this estimate.

□ Yes
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□ No
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If yes, please estimate the approximate amount. In answering this question, we do not need you to add up all of your invoices and receipts. Please simply give your best estimate of the total amount.

□ Less than $1,000
□ Between $1,000 and $5,000
□ Between $5,000 and $10,000
□ More than $10,000. If so, please write an estimate: $
□ Not able to be estimated. If not, why are you not able to estimate the out of pocket expenses which you have paid for?

Please do not attach any receipts/invoices or other records in relation to your pocket expenses to this form unless your expenses total more than $10,000. You should obtain and keep these documents for your own records as we may request these in the future.

EMPLOYMENT STATUS
Were you doing paid work at the time of your breast augmentation surgery with TCI:

□ Yes
□ No

If so, were you:

□ Receiving a wage or salary, or
□ Working as a contractor, or
□ Running your own business

If you were working at the time of your breast augmentation surgery with TCI, please answer the following additional questions. If not, please go to the Centrelink section.

What was your job description/position?
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If you were receiving a wage or salary, what was the name and address of your employer?

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What was your usual income after paying tax (as reported in your tax return) for a full year of work?

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Did you return to your usual work after your breast augmentation surgery with TCI?

□ Yes
□ No

Except for the recovery time advised by your doctor prior to the breast augmentation surgery with TCI, have you required time off work?

□ Yes
□ No

If so, approximately how much time did you take off work? (How many hours/days/weeks/months):

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If so, have you taken any of the time off work as paid sick and/or annual leave?

□ No
□ Yes

If yes, how much paid sick and/or annual leave did you receive?

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If you have not returned to work following your breast augmentation surgery, or if you have had to reduce the hours that you work due to your breast augmentation surgery, what is your current annual income after paying tax (according to your tax records)?

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Do you think that the injuries from your breast augmentation surgery with TCI will affect your ability to work in the future?

□ Yes
□ No

If you ticked yes, please tick one of the following:

□ Currently working or currently able to work but it is more difficult to do work duties due to injuries, or
□ Able to continue working and earning the same income but will need time off work for future surgery, or
□ No longer able to work at all and have stopped working, or
□ Currently unable to work but will try to return to work in the future, or
□ Currently working but likely to stop working in the future, or
□ Currently working at reduced hours and income, or
□ Needed to change jobs to a different type of job due to injuries.

Please give BRIEF details of any other important information regarding the impact of the breast augmentation surgery with TCI on your enjoyment of life, your income, your capacity to work and your capacity to care for yourself and others, including details of your job title and work (if your injuries have affected your work):

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CENTRELINK BENEFITS
Do you currently receive Centrelink benefits?

□ Yes
□ No

Have you received Centrelink benefits since your first breast augmentation surgery with TCI?

□ Yes
□ No

If so, what type of benefit?
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For what periods have you received Centrelink benefits? Please write the dates you started and stopped receiving benefits, or confirm that you continue to receive benefits if they have not stopped.

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OTHER CLAIMS
Have you ever made any other claims for compensation in respect of personal injuries suffered by you?

□ Yes
□ No

If yes:
What were the injuries for which you made a claim?

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Did you receive a settlement/judgment in relation to your claim?

□ Yes
□ No

If yes:
How much was the judgment/settlement?

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If yes,
When was the judgment/settlement?

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Did you claim economic loss in that claim?

□ Yes
□ No

If yes, were you partially or totally incapacitated?

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PHOTOS MUST BE ATTACHED TO THIS QUESTIONNAIRE FORM

Even if TCI took photographs, or if you provided your photographs to Turner Freeman, you MUST provide this completed questionnaire form to Turner Freeman with a copy of any photographs which you have (or can obtain yourself) from before any breast augmentation surgery with TCI and recent photographs showing your aesthetic outcome (how your breasts look) and any problems (like scarring) which you have.

If you do not have any photographs from before your breast augmentation surgery with TCI and cannot obtain these photos after checking all your emails, mobile and other records, you must at least provide current photographs which you can take yourself.

Each photograph must be dated with the date when the photo was taken and be attached to this form so we can identify the photograph as yours.

In order to ensure all photographs are properly identified you must attach all photographs to this questionnaire form and send them with the completed questionnaire form to Turner Freeman in ONE email to TCI.Forms@turnerfreeman.com.au

PLEASE DO NOT SEND NUMEROUS EMAILS ATTACHING YOUR PHOTOS.