Sclerotherapy Consent Form

Sclerotherapy Consent Form

Youthful Reflections, LLC 3 Geyser St., Suite 7 Ennis, MT 59729 (406) 925-3036 rnjordanstone@youthfulreflectionsmt.com
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Your Birthday*

MonthDayYear
Date
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
What are spider veins? Spider veins or "telangiactasia" are small veins under the skin usually developing from dilated blood channels connected with underlying larger veins.

What is sclerotherapy? Sclerotherapy is a method of treatment for spider veins in which a solution called a sclerosants is injected into the veins to cause eventual closing of the vein making it disappear.

Will sclerotherapy "cure" my spider veins? The majority of patients having Sclerotherapy will have marked improvement in their visible spider veins. Rarely are there poor results, with little or no improvement. ("Poor results" means the veins have not totally disappeared after several treatments.) Unfortunately, there is no cure for your genetic tendency to develop new spider veins.

How many sessions will I need? The number of treatments needed to clear of improve the condition differs from patient to patient, depending on the extent of varicose and spider veins present. The average number is 3.
When did you first notice enlarged or discolored veins?*
Which leg are you concerned about?

RightLeftBoth
Which of the following symptoms have you experienced?

Aching PainBurningStingingItchingSwellingCrampingRestless LegsDiscoloration or DarkeningLeg UlcersHeaviness
Do you take any hormone replacement therapy or birth control pills? Please list what you take.
Have you had any previous treatments? If so, When? Where? What Treatment?
Have you ever worn medical grade compression stockings/socks?

YesNo
Have you ever been diagnosed with:

Phlebitis (blood clots in legs)Deep vein thrombosis (DVT)Leg or ankle ulcersVaricose veinsAsthma
List any trauma to your legs, including softball, tennis ball injuries, surgeries, etc:
List any family members with vein problems
Do you regularly participate in any of the following?

Running/JoggingWeight LiftingWalkingTanning BedsSwimmingSmoking
Possible side effects and/or complications of Sclerotherapy:

The most common side effects experienced with Sclerotherapy include:

1. Hyperpigmentation - In most patients, the treated veins become darker immediately after the treatment. This usually fades in 2-4 weeks; however, in rare cases it can persist up to 12 months or can be permanent.

2. Matting - This refers to the development of new tiny veins in the treated area, which forms a "mat" of redness. It may occur 2-4 weeks after the treatment and usually fades with 4-6 months. It occurs in up to 18% of women receiving estrogen therapy and in 2-4% of all patients.

3. Trapped blood - occasionally the closing ofthe vein is slow to occur and a small pocket of blood remains as a dark blue clot. This can be removed with a small needle puncture within 2-4 weeks after treatment. This is NOT a dangerous form of clotting.

4. Ulceration - In less then 1% of patients receiving Sclcrotherapy, a small blister may form at the injection site, open and become ulcerated. Should this occur it usually heals within 8 weeks and the scar eventually returns to normal skin color.

5. Allergic reaction - Allergic reaction to the sclerosants is very rare; such reactions would be mile in the form of skin reaction of hives. Out office policy is equipped with medications that can be used in case of allergic reaction.

6. Itching - Mild itching or tingling may occur along the treated vein for up to 2 hours after the treatment and may persist a day or so.

7. Bruising - At the injection sight is very common, but usually disappears by 4 weeks.

8. Pain - An extremely small needle is used for injections into the vein and very little discomfort is associated with the actual injection site. Mild burning or tingling may be experienced immediately following the injections, but usually dissipate when hose are applied and walking resumes.

9. Phlebitis - In less then 0.1% of patients, swelling of the vein with pain may occur and may cause the ankles to swell. This is not dangerous and usually subsides in a few days.
A understand these possible side effects and complications, and I give consent to receive this treatment.
Post Treatment Instructions (You will be given instructions to take home at your appointment):

Walk for 20-30 minutes immediately following the treatment and twice daily for two weeks following procure.

Apply graduated compression hose immediately following the treatment. Sleep in them the first night and wear daily for 1 week as directed by your injector.

Avoid: prolonged heat exposure (hot tub, tanning beds, etc.) running or jogging. High impact aerobics, long periods of sitting or standing still.

Expect veins to look worse before looking better in approximately 4 weeks.

Remove any dressing applied at your treatment the next morning following your procedure.
I understand and will follow the above post instructions (You will receive these instructions to take home with you after your procedure).
CONSENT

By signing below, you understand the procedure, expectations, possible results and risks mentioned above, and you consent to receiving the treatment.
Patient Full Name
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Sclerotherapy Consent Form

CONSENT