• I ________________________(Patient or Guardian) hereby authorize Dr. _______________and Associates and Assistants, to perform the following procedure: sclerotherapy for my varicose veins and/or spider veins with sclerosant.
    I understand this means that the doctor, at times with ultrasound assistance, will inject medicine (sclerosing solution) with a very thin needle directly into the damaged vein. This solution causes an irritation in the vein wall that causes the vein to eventually disappear or fade.
    I understand that there have been reports in the medical literature of FOAM sclerotherapy (a type of sclerotherapy used for larger varicose veins) resulting in symptoms of stroke. I have discussed this with my doctor.
    I understand and have been told that this is not a medically necessary procedure.
    I understand that varicose veins or small spider veins can continue to develop despite treatment and that there are no guarantees with sclerotherapy for the treatment of unsightly veins.
    This authorization is given with the understanding that the procedure involves some risks and hazards.
    Some of the risks of this procedure are infection, scarring, allergic reactions, nerve injury (skin numbness or tingling), and pigmentation over vein area.
    I understand that the most common risks are bruising, pain, leg or ankle swelling, urticaria (hives) lumps or hematomas (which may need aspiration).
    I understand that the results of the procedure are not guaranteed and that no guarantee has been made to cure my vein disease.
    I understand and give consent for epinephrine, and/or antihistamine administration to me in case of severe allergic reaction.
    Patient consent: I have read and fully understand this consent form and understand that I should not sign this form unless all my questions have been answered and explained to my satisfaction. I have no further questions. Please note that all products and services provided are not subject to refund. However, they can be exchanged or be credited the precedingly paid amount or the remaining balance.
  • Date Format: MM slash DD slash YYYY