SCLEROTHERAPY TREATMENT CONSENT FORM

NAME:

DOB:

ADDRESS:

TEL:

ALLERGIES:

MEDICATIONS:

I, (your name) _____________________________________________

Have discussed the risks, benefits, and the cost of spider vein treatment with Dr Louisa Yim.

I give consent to have the choice of anaesthetic:

I give consent to have the following areas treated:

*

*

I am aware of potential side effects, and that I may need to take TIME OFF work depending on the areas treated. Some of the potential side effects discussed are:

- Pain, swelling, minor allergic reaction to the solution, inflammation of veins (phlebitis), staining of skin, matting and recurrence of veins, bruising, bleeding, need to wear compression bandages, skin ulcers

Other uncommon side effects discussed are:

- Uneven results, poor or no results requiring to have repeated procedures. Extremely rarely nerve injury

- DVT (best to have procedure done when on sugar pill if you are taking contraceptive pill) intra-arterial injection (extremely rare)

I have discussed all the medications/herbal supplements that I am taking.

I am not aware of any contra-indications that may prevent this treatment:

- Diabetes, blood clots, history of complicated spider veins treatment, allergies to Laureth-9 or saline products, cancer, active infection or fever, skin ulcers, history of poor wound healing.

I understand the post treatment care plan and will follow the instructions as directed.

I have read the above information and I am happy to proceed.

Signed: Date: ________/________/_______