Microsoft word - sclerotherapy informed consent

R TELANGIECTASIAS “S
This form is designed to provide you with the information yo u need to make an informed decision about whether to have sclerotherapy performed. If you have any questions or do not understand the potential risks, please do not hesitate to ask us. Sclerotherapy is a popular method of eliminating superficial telangiectasias (“spider veins”) in which a solution, called a sclerosing agent, is injected into the veins. The injection causes a sclerosis or the formation of fibrous tissue in the vessel subsequent to an inflammatory reaction. This process causes a gradual fading of the treated vessel over a period of several weeks to several months. Most people treated will have good results; however, there is no guarantee that sclerotherapy will be effective in every case. Approximately 10% of patients who undergo sclerotherapy have poor to fair results. (“Poor results” means that the veins have not totally disappeared after six treatments.) In very rare instances, the patient’s condition may become worse after sclerotherapy treatment. I also understand the sclerosing solution being used and it’s present FDA status. The number of treatments differs from patient to patient, depending on the extent of spider veins present. One to six or more treatments may be needed; the average is three to four. Individual veins usually require one to three treatments. 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. Arnica is a homeopathic remedy shown to reduce 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 months. Predisposing factors include: those with body iron stores, drug therapy, NSAIDS (non-steroid anti-inflammatory), elevated histamine states, hormones and Pain: A few patients may experience mild pain at the site of the injection. The veins may be tender to the touch after treatment. This pain is usually temporary, in most cases lasting from one to seven days at most. e : This may present as a tender bump at a treatment site. The use of prescribed compression hosiery will minimize this possibility. (especially when treating Reticular Veins) Other side effects include a burning sensation during injection of some solutions and the development, usually temporary, of new tiny blood vessels; transient swelling of the vein might cause the ankles to swell, temporary superficial blebs or wheals (similar to hives); and, very rarely, wound infection, poor healing or scarring. IPL therapies can be utilized to treat small spider veins less than 1mm in size, which are more difficult to treat with conventional sclerotherapy injections. Do you have a history of vascular problems? For example, varicose vein problems, blood clots, leg fractures, cellulites, leg swelling. YES / NO I acknowledge that I have read, understand and have received a copy of this sclerotherapy informed consent for treatment. I also certify that I am not pregnant and do not have any of the disease processes* listed above. I also certify if any changes occur in my medical history/health I will notify the office immediately.

Source: http://rmsirmo.boomtime.com/sclerotherapy-informed-consent.pdf