VARICOSE VEIN TREATMENT CONSENT FORM

It is our aim to provide the most professional service to you and make sure your expectations are met. We ask that you read this important information on possible adverse outcomes prior to signing to consent to the procedure

Hyperpigmentation: In almost every patient the veins become darker immediately after the procedure and with the larger veins they may be a palpable cord under the skin. This always disappears with time, but the brown color may persist for over 8 months especially with olive skinned individuals.

Sloughing or skin ulcers: Very rarely, the skin may breakdown causing a small ulceration at the injection site that heals slowly over one to two months. The scar that follows should return to normal color or may remain permanently white. This occurrence usually represents a burn from the laser or an injection into or near a small artery and is not always preventable. We use the safest and most forgiving sclerosant to minimize this risk to your skin.

Allergy reaction: Very rarely, a patient may have an immediate systemic allergic reaction to the sclerosant used. This can be treated in the clinic with medications readily available.

Tender veins: You may experience mild itching along the vein. This itching normally lasts only an hour or two but may persist for a day or so. A few patients experience some temporary pain and some bruising, usually at the site of the injection. The veins may be tender to touch after treatment and an uncomfortable sensation may run along the vein. This may occur some weeks after the treatment (superficial phlebitis) and is associated with the treatment of the larger varicose veins. Please let us know, as although it is temporary, we would like to see you assess the veins and give you further advice.

Nerve sensations: rare, a temporary numbness or tingling sensation in an area

Telangiectatic matting: This is rare and refers to the development of new, tiny, blood vessels in the treated area. This is usually temporary, occurring 2-4 weeks after treatment and lasting 4 to 6 months. Further treatment is sometimes necessary to achieve best results.

Ankle swelling Sometimes a few weeks after treatment, it usually resolves in time and is lessened by wearing compression hosiery.

Deep Vein Phlebitis/Thrombosis (DVT): There is a possible danger of your deeper healthy veins becoming irritated and deep vein thrombosis forming. Statistics on this risk vary from 1:500 to 1: 10,000). A deep vein thrombosis has the further possibility of pulmonary embolus (a blood clot to the lungs) or a post-phlebitis syndrome (in which the deep vein remains compromised resulting in permanent swelling of the leg). We recommend walking for at the very least 15 minutes immediately after this treatment (preferably accompanied) and 45 minutes daily for the first 2 weeks.

By signing below, I acknowledge that I have read and understood this information and that I have been adequately informed of the risks of treating my veins and I hereby consent to sclerotherapy treatment. I have been given a post treatment information “Instructions for patients having varicose vein treatment”.

I am aware that payment will be made at the time of treatment. In the event of a default in Payment the customer agrees to Pay all collection and legal fees.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.