Before the procedure, I have read all of the provided material about the procedure of sclerotherapy.

I understand that the sclerosing agents that may be used for my treatment in this office are hypertonic saline, sotradecol or polidocanol. I acknowledge that adverse reactions may occur which include: allergic reaction, mild systemic reaction (headache/nausea/vomiting) bruising, stinging, transient hyper- or hypopigmentation, blistering, superficial ulceration, clot formation, swelling, telangiectatic matting, superficial thrombophlebitis and pulmonary embolism.

I understand that sclerotherapy will not completely eliminate my spider veins, but that after repeated treatments (usually 3-4)I can expect up to a 60-80% improvement. I also understand that results are not guaranteed and I may have no resolution or worsening of my veins after treatment. It has been made clear to me that optimum results require that I follow the pre- and postoperative instructions (i.e. discontinuing blood thinning agents, wearing compression stockings, daily walking, avoiding hot tubs and vigorous exercise).

I do expect that due to the natural healing process, bruising and even reddening of my treated vessels may cause my legs to look worse before they look better. I understand that there are contraindications for sclerotherapy which include the following instances: previous allergic reaction to injected agent, active thrombophlebitis, active infections, poor circulation, certain diseases of the blood or blood vessels (hypercoagulable states, blood dyscrasias), immobility (or confinement to bed), a history of pulmonary embolus (clot in lung), uncontrolled diabetes or asthma, toxic hyperthyroidism, lung or skin diseases, large abdominal and pelvic tumors, tuberculosis, acute respiratory or skin diseases, lymph edema. Any of these conditions would exclude me from undergoing the procedure of sclerotherapy.

Most common side effects include: Bruising: Lasts from one to several weeks. Use of support hose may be recommended and avoidance of alcohol and anticoagulant medication for 72 hours prior to each treatment session may minimize effect. Transient Hyperpigmentation: Approximately 30% of patients who undergo Sclerotherapy notice a discoloration of light brown streaks after treatment. In almost every patient, the veins become darker immediately after the procedure (but then go away.) In rare instances,this darkening of the vein may persist for four to twelve months. Pain:A few patientsmay experience mild pain at the site off the injection. The veins may be tender to the touch after treatment. This pain is usually temporary, in most cases lasting from 1-7 days at most. Blood accumulation in treated vessel:This may present as a tender bump at treatment site. The use of prescribed compression hosiery will minimize this possibility (especially when treating Reticular Veins.)

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.