Gone in 52 seconds: Inside Australia’s telehealth injectables gold rush

“You’re in good hands,” assures the doctor through a tinny iPad speaker.

The patient, a blonde woman in her late 30s, nods at the iPad screen as doctor John Delaney, the co-founder of Australia’s largest telehealth cosmetic injectables company, Fresh Clinics, lists potential risks of her upcoming anti-wrinkle treatments.

“Bleeding, bruising, infection or swelling can occur with any injection,” he says rapidly in the video call. “There is a small chance that the anti-wrinkle injection can cause a droop of the muscle.”

Moments later, Delaney has remotely written a script for the anti-wrinkle injection which a nurse will administer into the woman’s forehead. The consultation lasts 52 seconds.

Calls like this are the foundation of Australia’s $4 billion and fast-growing world of cosmetic injectables. Here, nurses in stores onboard customers using surveys before doctors issue scripts for Botox, dermal fillers, fat dissolving and other beauty treatments after consultations lasting less than a few minutes.

The boom has sparked concerns among beauty industry activists, academics and cosmetic doctors who prescribe in person. They claim the industry’s processes, which Fresh describes as sitting at the “intersection of medicine and commerce”, fail to meet the regulator’s guidelines governing patient consultations.

The critics argue that whatever warnings are provided by nurses, more time is needed with doctors, preferably in the room.

This is the backdrop to a looming battle between the providers and federal and state regulators trying to keep a lid on standards for procedures in which patients can be put at risk.

This masthead found evidence of many patients harmed in cosmetic injectable procedures across the country since 2016; eight have been permanently blinded by dermal fillers and anti-wrinkle treatments. A further 81 were left with eye disorders, according to Therapeutic Goods Administration reports.

Founder and co-owner of Fresh Clinics, John Delaney.

“The most recent case of blindness was a female patient in August 2024,” a TGA spokesman said.

Delaney’s 52-second video is not an outlier. It, and another detailing an equally short consultation, was used as part of a training module for new doctors at Fresh Clinics and posted to their website.

The first video features the patient’s face and private details including her name, phone number, date of birth and home address.

In a second video, also 52 seconds long, a patient appears with her brow prepped and marked up for Botox before Delaney proceeds to write her script.

The videos were taken down after this masthead asked questions about them last week. Delaney said publishing the footage containing private information was “an oversight”, and that the company had apologised.

The federal medical watchdog, the Australian Health Practitioner Regulation Agency, told this masthead that it was “difficult to see how a doctor could meet all of their obligations in a 60-second consultation”.

These AHPRA guidelines include obtaining informed consent, protecting patient privacy, accepting responsibility for evaluating information and confirming the identity of the patient.

Delaney, however, made no apology for the speedy service when contacted by this masthead. “The timing of each consultation is based on the doctor’s assessment of complexity,” Delaney says.

Delaney said that before a patient sees a Fresh Clinics doctor, a nurse conducts a consultation covering treatment risks. These risks are also included in the patient’s consent paperwork, which must be completed first.

“When the doctor joins the call, they’re briefed by the nurse, who will flag any relevant health issues or medications that the patient might have. The doctor then reviews the patient intake form and assesses the patient’s suitability.”

Doctors in this market are expected to quickly issue telehealth scripts for patients seeking dermal fillers and Botox. Nurses who call Fresh Clinics get to choose which doctor writes a prescription for them – one former Fresh doctor says those who take too long are chosen less often by nurses.

“People forget that this is medicine – this is not a visit to the hairdresser, this is a medical situation that can cause terrible tissue damage,” said cosmetic physician Ronald Feiner, medical dean of the Australasian College of Cosmetic Surgery and Medicine.

While the procedures performed by Fresh Clinics’ co-founder in those videos went to plan, other patients have not been so lucky.

Fresh publicly states it deals with 1000 complications annually, from the thousands of small beauty clinics it services across Australia.

Delaney says only 0.1 per cent of Fresh Clinics’ patients experience complications and the majority are mild: “A slight droop of the eyelid or eyebrow, or mild inflammation around the location of injection.”

But Feiner says 1000 complications a year is concerning. He is also a co-ordinator at the International Master Course on Ageing Science, which hosts the world’s leading cosmetic dermatology and plastic surgery meeting, and reviews complications lodged by doctors from around the world.

Feiner says he has received calls from nurses working with other telehealth providers whose patients had experienced acute complications and then not been able to contact their telehealth prescribing doctor.

“Or they have contacted them, and [the patient is] totally insecure in what the response of that doctor has been,” he said.

Amid a critical shortage of doctors to staff GP clinics, the telehealth industry has ballooned since the pandemic, with economists at Grand View predicting cosmetic injectables will grow from its $4 billion annual spend to $9 billion in five years.

The telehealth boom is driven by doctors issuing online scripts – often without Medicare rebates – for treatments such as medicinal cannabis, erectile dysfunction, weight loss and hair loss, as well as injectables.

A recent job ad from Gold Coast-based Angel Aesthetics outlines the role bluntly.

“A one to two-minute consult with the patient will occur and all you need to do is fill out the patient’s script, which takes five seconds,” the ad reads. “You will be paid $15 a call/script. You will roughly receive 150-200 calls a week.”

An Angel Aesthetics manager said doctors reviewed all patient documentation before prescribing, including medical history and a body dysmorphic disorder screening.

During video consults nurses summarised key details and doctors confirmed critical information.

Most patients were aged 18 to 30, an age group with few medication or allergy concerns, she said.

“Many consultations are brief and can be completed within approximately two minutes when no additional concerns are raised,” she said, though some took longer.

The company also had in-house doctors that visited clinics.

Fresh Clinics is the fastest-growing injectables telehealth provider, with a Deloitte report noting its 1363 per cent growth from 2019 to 2022. Fresh is used by between 1500 and 2000 nurses running their own beauty clinics, Delaney has said.

Fresh serves 14 per cent of Australia’s 9200 injectables clinics just five years after launching. It charges the nurses who perform the procedures $25 for each telehealth consultation. Nurses then charge clients about $300 for simple Botox, about $650 for lip filler and upwards of $850 for collagen stimulators (synthetic injectables that stimulate collagen production).

Fresh Clinics also sells nurses products to inject into patients’ faces and bodies, buying in bulk from pharmaceutical giants such as Allergan, Galderma, Merz and Hugel.

A Fresh Clinics price list from November shows nurses save up to 41 per cent off the standard price set by the pharmaceutical companies manufacturing anti-wrinkle toxins, dermal fillers and other drugs.

Fresh Clinics’ strong growth attracted investor Ellerston Capital, which spent $32 million in November to acquire a stake in the company as it expands into the US. Ellerston told clients the investment was driven by “trends in the ageing population and rise of social media fuelling demand”.

Delaney – who founded Fresh Clinics with a fellow doctor in 2018 after the pair launched and then closed a hair-loss telehealth company – said patient safety was the company’s foremost concern, and it complied with all regulations.

He said the company selected responsible nurses with experience in cosmetic injecting who assessed patients when they came into clinics.

“Doctors will discuss the risks, give the patient an opportunity to ask any questions and at the end of the consultation, the doctor can either authorise treatment or, if that patient is not medically suitable, decline treatment,” he said.

“Fresh Clinics exists to enhance compliance with regulatory standards, help clinics navigate the complexities of the industry while ensuring high standards of care and medical oversight.”

He said that in the rare instances in which complications arose, the company’s specialised complications unit provided support to patients, including through a 24/7 emergency hotline.

Delaney said he “hit out at any suggestion nurses weren’t qualified to perform injectable procedures”.

“Nurses delivering injections with doctor oversight is consistent with long-standing medical practice,” he said.

Among those concerned about the exponential growth in telehealth injectables is Queensland cosmetic physician Ansulette Kay.

“The prescribing doctor and nurse may never have met, and the doctor may have no knowledge of the nurse’s skill level,” she says. “Yet the nurse is effectively entrusted with assessment, treatment planning, consent and the procedure itself, while the patient is sometimes left without access to a knowledgeable doctor who is there to protect their interests.”

A vascular occlusion of the tongue posted to Fresh Clinics’ website by one of its doctors. The serious vascular occlusion – when blood flow to an artery is blocked – affected the patient’s chin and tongue due to a filler being injected into their chin. The patient recovered but the Fresh doctor said she “experienced extreme pain”.Credit: Fresh Clinics

Kay is among a small group of doctors who last year urged AHPRA to urgently overhaul the non-surgical cosmetic sector.

She argues it is “more dangerous to patients than cosmetic surgery, because of easy access to treatments, cheaper pricing, lower perceived and disclosed risks and aggressive marketing”.

One risk is vascular occlusion, which occurs when dermal filler blocks a blood vessel.

If not treated quickly, it blocks oxygen from skin and tissue, leading to pain, skin damage and tissue death – known as necrosis.

Most medical practitioners administering injectables will have a patient who suffers a vascular occlusion during their career.

One Fresh doctor said recently that he’d managed “some pretty bad occlusions” including “four that involved the tongue”. He said he successfully treated all four. The doctor cited one instance on Fresh’s website, saying that the patient had recovered but had “experienced extreme pain”.

Other incidents happen too. In February two nurse injectors whose prescriptions are done by Fresh posted on Instagram about post-injection patient collapses. One had a seizure, the other anaphylaxis.

Amid the growth of the business and the warnings, the regulatory landscape is contested country. In December, Queensland Health issued a fact sheet outlining the industry’s legal obligations. No laws had changed; it was simply restating the rules.

But the move threw the sector into disarray. It stated that only doctors and nurse practitioners (a nurse with a higher level of training, and able to issue prescriptions) can purchase Botox and cosmetic fillers.

“Generally registered nurses are not permitted to purchase [these] medicines,” Queensland’s health department said. “Doctors and nurse practitioners cannot buy stock for a place that they do not practice from, which includes locations for which telehealth is provided.”

NSW Health confirmed to this masthead its position was the same as Queensland’s, with injectables such as botulinum toxin and dermal fillers only allowed to be purchased by or on behalf of an authorised practitioner, such as a medical practitioner, nurse practitioner or dentist.

The NSW Health Care Complaints Commission said it was “aware of allegations involving Fresh Clinics and is currently assessing the matter. To ensure a fair and robust process, we will not comment on the complaint or individual practitioners.”

Enforcing Queensland’s and New South Wales’ reading of the laws could dismantle the telehealth model for cosmetic injectors in Australia, according to lawyers at major firm Mills Oakley.

Victoria’s Department of Health, however, said nurse-led businesses could apply for a permit to obtain, possess and use substances such as botulinum toxins and hyaluronic acid.

Fresh is attempting to change the laws, which Delaney agrees is Queensland Health saying “that the doctor should be on site in any clinic where medicines are ordered and used”.

He compares rules surrounding cosmetic injectables to those around nursing homes, where nurses often deal with medicines without doctors present.

This month, the company started a petition urging injector nurses in Queensland to rail against the law, saying they “disproportionately impact women-led businesses”.

In a recent podcast, Delaney also labelled concerns about the industry as “misogynistic”.

Fresh has also stepped up campaigning, posting on social media daily about the importance of safety and training. (The company also runs two-day courses for nurses so they can become injectors – or “nursepreneurs” – for $6270.)

An Instagram post promoting a Fresh Clinics “boot camp”. The two-day $6270 course is for nurses wanting to start a cosmetic injectable business.Credit: Fresh Clinics

Delaney went to a National Press Club lunch in January, saying in an Instagram post that he was in Canberra to advocate for “one of the fastest-growing areas of female entrepreneurship in the country”.

Maddison Johnstone, co-director of patient advocacy group Operation Redress, rejects Delaney’s claim that there is a misogynistic edge to the Queensland regulator’s actions.

“It is not sexist to bring an out-of-control industry – an industry causing actual harm to mostly female patients – into line with the rest of the medical sector,” she said. “You could argue it is sexist not to.”

Michael Fraser and Maddison Johnstone of patient advocacy group Operation Redress.Credit: Paul Harris

Her co-director, Michael Fraser, said regulators needed to set up a mandatory register of complications.

“Cosmetic injectables are clinically unnecessary discretionary medical treatments that carry real short-term and long-term risks, with many complications going unreported,” he said. “Governments would take the risks and harms of this industry more seriously if there was a mandatory register of complications. Introducing telehealth to speed up consults, while driving products and profits, positions the patient as the mechanism to extract maximum returns.”

He said the current model encouraged doctors to have fast consultations with patients to earn more money.

“If their consults are as quick as 60 seconds as reflected in some training videos, they could be earning $900 an hour,” he said.

The issue was a hot topic of discussion at Cosmedicon, a conference staged by the industry’s main magazine, Aesthetic Medical Practitioner, earlier this month.

Cosmetic doctor Tom Parmakellis told the crowd that some telehealth doctors, without identifying what practice or company they were from, did up to 300 cosmetic injectable consultations in one day. “That’s completely ridiculous,” he said.

Kate Evans, director of AHPRA’s regulatory response unit, also expressed her concerns on the same panel. “There are obligations that there must be good and safe clinical care … it’s very hard to see how 300 patients a day could ever meet the guidelines or the code,” she said.

Speaking generally, an AHPRA spokesman said it was concerned about unprofessional conduct and patient harm in the cosmetic procedures industry, and received regular reports of “inappropriate consultations”.

“The interaction between the cosmetic procedures industry and practitioners providing virtual care is of growing interest, given anecdotal reports and regulatory intelligence in relation to patient harm and unethical practice,” he said. “Some new models of care may take advantage of consumer demand for certain treatments and compromise good patient care.”

Since September 2022, the watchdog has taken action against 16 practitioners performing non-surgical cosmetic procedures, mainly injectables. Five were nurses.

Fresh Clinics has also come under attack from within over its internal culture. Several former senior staff at the firm have told this masthead they left because of disputes with its founders, but declined to be quoted.

The company’s former head of events and conferences, Nicole Dabeau, went to the Federal Court complaining in her statement of claim about a “bullying culture at Fresh Trading”.

Dabeau said she had told a senior Fresh employee that she “felt she was on the receiving end of what felt like Mean Girls”. In Fresh’s defence, filed with the court, the company denied the claim, saying the senior employee could not remember the conversation.

Dabeau also claimed the company had represented to her that “she would have a million dollars in her bank account” if she cashed out a share offer. The co-owner denied this. Dabeau never got the opportunity because she was made redundant in 2023.

Her court documents refer repeatedly to “the toxic burnout culture” within Fresh, saying that employees suffered “from mental health issues because of the excessive workload”. The company denied this claim in its court defence.

Dabeau declined to comment when approached. Fresh Clinics said the company had “respectfully settled this case”.

Dr Christopher Rudge, a health law expert at the University of Sydney Law School, said telehealth regulations were too ambiguous.

He said they did not clearly define whether doctors needed to supervise nurses administering cosmetic injectables in person, or at all.

“Clinics are aware that the guardrails are a bit ambiguous,” he said.

He said it could also be unclear who would be liable if something went wrong.

Dr Damien Grinsell is increasingly treating patients who have suffered complications.

The fellow of the Royal Australasian College of Surgeons has performed surgery on patients suffering infections after dermal filler eroded their skin. In milder cases, filler has migrated to the wrong place and needs dissolving, or replacement with fat grafting.

“There’s a trend around the world for plastic surgeons to not use filler as much because the complication rate is so high,” he said, pointing out that the tear trough area beneath the eye was particularly risky.

He said skin thickness affects treatment success, but was hard to assess via video consultation.

“If you’ve got super-thin skin, you’re almost certainly going to get a poor outcome,” he said. “These are critical things that need to be assessed.”

Mark Ashton, a specialist plastic surgeon and professor of surgery and anatomy at the University of Melbourne.Credit: ABC/Andy Ware

Mark Ashton, a specialist plastic surgeon and professor of surgery and anatomy at the University of Melbourne, said telehealth had weakened protections for patients.

“I am not at all supportive of allowing patients to have fillers injected in shopping centres and the prescribing doctor being on the phone. Remotely. Sometimes in a different state,” he said.

Dermal fillers, according to Ashton, are more dangerous than anti-wrinkle injections.

“Dermal filler injected into an artery by mistake can cause devastating damage,” he said. “People can go blind within seconds. It can cause a stroke. It can cause necrosis. Patients can end up with a dead patch of skin on their forehead, or lose their nose or lip.”

Sean Arendse, an emergency doctor who works at hospitals in Melbourne’s south-east, sometimes treats patients who present with vascular occlusions caused by cosmetic injectables.

“A lot of times when they have a vascular occlusion, [the cosmetic injector] will … go into denial … and then sit on it,” he said.

“The sooner you treat these occlusions the higher the success rate of not losing skin or scarring someone. We’re talking a matter of hours – not days. We see things that have been left for two or three days.”

Arendse is also founder of Flawless Rejuvenation Skin Clinic and serves on the Cosmetic Physicians Society of Australia’s Board. He, too, is concerned about doctors providing scripts via telehealth to interstate patients.

“If something goes wrong, you as a doctor have taken responsibility for that medication that’s been administered to the patient,” he said. “If you’re a flight away, how can you manage that complication?”

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