Sclerotherapy Consent

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This form is designed to provide you with the information you will need to make an informed decision about whether to have treatment performed.  It is intended to educate, not scare you.  If you have any questions at any time or do not understand any potential risks, please ask for more information.

PLEASE INITIAL YOUR UNDERSTANDING OF EACH PARAGRAPH BELOW:

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Varicose Veins and Spider Veins are chronic, recurrent conditions. Current treatments control the condition, but do not cure it.  Surgically removed veins cannot come back, and veins, which are completely sclerosed will generally not return.  However, your body’s tendency for developing new veins will not be relieved by this or any other form of treatment. 

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The treatment of large, (bulging) varicose veins is done with a variety of minor surgical procedures or real time, ultrasound directed, sclerotherapy.  Medium to small bulging veins, visible blue veins and spider veins are best treated with sclerotherapy and sometimes lasers.  Your particular condition may require a combination of any or all of these treatments.    

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SCLEROTHERAPY: Sclerotherapy is a method of eliminating varicose veins and superficial telangiectasias (spider veins) by injecting a limited amount of an FDA approved, liquid sclerosing agent into the undesired or diseased veins.  Most people who have sclerotherapy performed will be experience significant improvement. Sclerotherapy never achieves one hundred percent improvement.  Approximately 10% of patients who undergo sclerotherapy have fair to poor long term results.  In rare instances, the patient's condition may become worse after sclerotherapy treatment. 

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The number of treatments needed to improve your veins depends on the extent of the problem.  One to six or more treatments may be needed; the average being two to four.

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The best results from sclerotherapy have been achieved by patients who wear tight compression hose for 1 to 2 weeks after each treatment and who have treatments done every 4 to 8 weeks.  Compression allows the sclerosant to work where it was injected and doesn’t allow blood from above to re-open the collapsed veins before they scar down and are eventually absorbed back into the body.

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RISKS / SIDE EFFECTS: The most common side effects experienced with sclerotherapy treatment include: bruising, swelling transitory pigmentation, small ulcerations or scars and secondary matting (tiny spider veins).

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TRANSIENT HYPERPIGMENTATION:

Approximately 20% of patients who undergo sclerotherapy notice a discoloration (light brown streaks) after treatment.  This usually fades in 4 to 12 months.  In rare instances, this darkening of the skin may persist.  Hyperpigmentation can sometimes be improved with Intense Pulsed Light treatments and various creams to bleach out the pigment.

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SLOUGHING:

This occurs in less than 1% of patients who receive sclerotherapy.  An ulceration near the injection site that heals slowly over a few months.  Initially, a blister may form, open, and the underlying tissue becomes ulcerated.  After slowly healing, this usually leaves a scar. (This happens from unintentional injection into or near a small non-visible artery and is not preventable).

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ALLERGIC REACTIONS:

Very rarely, a patient may have an allergic reaction to the sclerosing agent.  The risk of this is greater in patients who have a history of allergies.

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PAIN:

A few patients may experience moderate to severe pain, usually at the site of the injection.  Veins may be tender to the touch after treatment.  Usually this is temporary, but can last for months.

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TELANGIECTATIC MATTING:

Tiny blood vessels can appear in the area of the treated vein.  This occurs 2 to 4 weeks after treatment and usually resolves within 4 to 6 months on its own.  It occurs in up to 18% of women receiving estrogen therapy and in 2% to 4% of all patients.

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ANKLE SWELLING:

Sometimes occurs after treating veins in the lower leg.  It usually resolves in a few days to a few weeks.  It occurs more often after treatment of large varicose veins.  Ankle swelling is lessened by wearing prescribed support/compression stockings as directed.

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RARE SIDE EFFECTS:

Deep vein phlebitis or thrombosis (irritation or clot) are very rare complications that occurs in approximately 1 out of every 10,000 (0.01%) patients treated.  The dangers of phlebitis include the possibility of pulmonary embolus (a blood clot carried to the lungs which could cause death) and post phlebitic syndrome which can result in permanent swelling of the arm or leg.  Deep vein thrombosis (DVT) requires treatment by hospitalization for intravenous blood thinning agents for several days and then at least 3 months on oral anticoagulants.     

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OTHER RISKS:

I am also aware that there are other risks that may accompany any surgical procedure.  They are more rare, but include: loss of blood, infection, inflammation in the venous system with formation of a thrombus (clot), postoperative bleeding, and nerve trauma that may lead to temporary or permanent numbness. 

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ALTERNATIVE TREATMENTS:

I understand that alternative treatments for varicose veins exist.  Varicose veins and spider veins are not life-threatening conditions.  Treatment is not mandatory.  Insurances rarely cover the cost of these treatments. 

Some patients get adequate relief of symptoms from wearing graduated support stockings. 

Pulsed Dye and Nd:YAG lasers can be used to treat superficial veins that are 3 millimeters or less in diameter.  PDL’s may cause temporary, dark, purple-red marks called purpura over the areas that were treated. The marks fade in several weeks, but may leave brown discolorations in some patients. 

Other lasers can treat small (1-2mm), superficial vascular and pigmented lesions as well.  Multiple sessions are required for any kind of laser treatment.

Ambulatory Phlebectomy is another method to remove superficial varicose veins under “tumescent anesthesia” in the office.  Tiny (2-3mm) incisions are made every inch or so over the diseased vein.  A tiny instrument is used to hook portions of the vein, tease it out and then excise it.  The next area down is treated similarly.  Steri-strips pull the edges of the incisions together and a compression dressing is applied.

RadioFrequency and Laser tipped catheters can be threaded through the skin into larger, diseased veins that are relatively straight.  This is done with local anesthetic in the office or an out-patient surgery center. 

Surgical stripping or surgically tying off diseased veins may treat large varicose veins.  This procedure is done by a general or vascular surgeon in an outpatient surgical facility or hospital while the patient is under general anesthesia.  Risks of vein stripping are similar to sclerotherapy with the additional risks of the general anesthetic.  General anesthesia has some rare, but serious, associated risks including the possibility of paralysis, brain damage, and death.

Another option is to receive no treatment at all.

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POSSIBLE COMPLICATIONS OF NOT RECEIVING TREATMENT:

In cases of large varicose veins, spontaneous phlebitis (inflammation) and/or thrombosis (blood clot) may occur with the further risk of possible pulmonary embolus.  Chronic swelling and skin breakdown and discoloration may develop around the ankles and lower legs of patients with long-standing varicose veins and underlying venous disease.

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PROPOSED TREATMENT RESULTS:

I know the practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot guarantee results.  While the overwhelming number of patients have noted gratifying symptomatic and cosmetic improvement, specific results cannot be guaranteed.  I also recognize the need and agree to keep Dr. Zimmerman/Dr. Lee and staff informed of any changes in my medical condition and cooperate with them in my after-care, including any changes in my permanent address and phone number.

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CONSENT FOR VEIN SURGERY:

I hereby authorize Dr. Edward Zimmerman and/or associates, to perform Sclerotherapy on me, attempting to improve the symptomatology and/or appearance of my veins.  This make require multiple visits initially and periodic maintenance treatments thereafter.

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CONSENT FOR ANESTHESIA:

I consent to taking a mild sedative or anxiolytic like Valium or Xanax before my procedure if I want/need it.  (Please advise us if this is something you prefer.  You must have someone available to drive you home if you are medicated.)  I also consent to the use of "local" injectable numbing medicine (LIDOCAINE) during the procedure.  Risks involved with the use of local anesthesia including allergic or toxic reactions and even cardiac arrest (very, very rare).

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CONSENT FOR PICTURES:

Digital photographs will be obtained periodically for your medical record-to document your initial problems and the results of your therapy over time.  These pictures are kept confidential unless you give permission for their use in advertising or teaching.

INFORMED CONSENT:

By signing below, I acknowledge that I have read the foregoing informed consent form and that I understand the process, purpose, risks and expected results of Sclerotherapy, alternative methods of treatment, and the risks of not treating my condition.

I have had any opportunity to ask any questions and had them answered to my satisfaction.

I hereby consent to vein treatments.

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Sclerotherapy Consent

Sclerotherapy Consent

Patient First Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Last Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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This form is designed to provide you with the information you will need to make an informed decision about whether to have treatment performed.  It is intended to educate, not scare you.  If you have any questions at any time or do not understand any potential risks, please ask for more information.

PLEASE INITIAL YOUR UNDERSTANDING OF EACH PARAGRAPH BELOW:

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Varicose Veins and Spider Veins are chronic, recurrent conditions. Current treatments control the condition, but do not cure it.  Surgically removed veins cannot come back, and veins, which are completely sclerosed will generally not return.  However, your body’s tendency for developing new veins will not be relieved by this or any other form of treatment. 

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

The treatment of large, (bulging) varicose veins is done with a variety of minor surgical procedures or real time, ultrasound directed, sclerotherapy.  Medium to small bulging veins, visible blue veins and spider veins are best treated with sclerotherapy and sometimes lasers.  Your particular condition may require a combination of any or all of these treatments.    

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

SCLEROTHERAPY: Sclerotherapy is a method of eliminating varicose veins and superficial telangiectasias (spider veins) by injecting a limited amount of an FDA approved, liquid sclerosing agent into the undesired or diseased veins.  Most people who have sclerotherapy performed will be experience significant improvement. Sclerotherapy never achieves one hundred percent improvement.  Approximately 10% of patients who undergo sclerotherapy have fair to poor long term results.  In rare instances, the patient's condition may become worse after sclerotherapy treatment. 

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

The number of treatments needed to improve your veins depends on the extent of the problem.  One to six or more treatments may be needed; the average being two to four.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

The best results from sclerotherapy have been achieved by patients who wear tight compression hose for 1 to 2 weeks after each treatment and who have treatments done every 4 to 8 weeks.  Compression allows the sclerosant to work where it was injected and doesn’t allow blood from above to re-open the collapsed veins before they scar down and are eventually absorbed back into the body.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

RISKS / SIDE EFFECTS: The most common side effects experienced with sclerotherapy treatment include: bruising, swelling transitory pigmentation, small ulcerations or scars and secondary matting (tiny spider veins).

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

TRANSIENT HYPERPIGMENTATION:

Approximately 20% of patients who undergo sclerotherapy notice a discoloration (light brown streaks) after treatment.  This usually fades in 4 to 12 months.  In rare instances, this darkening of the skin may persist.  Hyperpigmentation can sometimes be improved with Intense Pulsed Light treatments and various creams to bleach out the pigment.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

SLOUGHING:

This occurs in less than 1% of patients who receive sclerotherapy.  An ulceration near the injection site that heals slowly over a few months.  Initially, a blister may form, open, and the underlying tissue becomes ulcerated.  After slowly healing, this usually leaves a scar. (This happens from unintentional injection into or near a small non-visible artery and is not preventable).

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

ALLERGIC REACTIONS:

Very rarely, a patient may have an allergic reaction to the sclerosing agent.  The risk of this is greater in patients who have a history of allergies.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

PAIN:

A few patients may experience moderate to severe pain, usually at the site of the injection.  Veins may be tender to the touch after treatment.  Usually this is temporary, but can last for months.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

TELANGIECTATIC MATTING:

Tiny blood vessels can appear in the area of the treated vein.  This occurs 2 to 4 weeks after treatment and usually resolves within 4 to 6 months on its own.  It occurs in up to 18% of women receiving estrogen therapy and in 2% to 4% of all patients.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

ANKLE SWELLING:

Sometimes occurs after treating veins in the lower leg.  It usually resolves in a few days to a few weeks.  It occurs more often after treatment of large varicose veins.  Ankle swelling is lessened by wearing prescribed support/compression stockings as directed.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

RARE SIDE EFFECTS:

Deep vein phlebitis or thrombosis (irritation or clot) are very rare complications that occurs in approximately 1 out of every 10,000 (0.01%) patients treated.  The dangers of phlebitis include the possibility of pulmonary embolus (a blood clot carried to the lungs which could cause death) and post phlebitic syndrome which can result in permanent swelling of the arm or leg.  Deep vein thrombosis (DVT) requires treatment by hospitalization for intravenous blood thinning agents for several days and then at least 3 months on oral anticoagulants.     

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

OTHER RISKS:

I am also aware that there are other risks that may accompany any surgical procedure.  They are more rare, but include: loss of blood, infection, inflammation in the venous system with formation of a thrombus (clot), postoperative bleeding, and nerve trauma that may lead to temporary or permanent numbness. 

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

ALTERNATIVE TREATMENTS:

I understand that alternative treatments for varicose veins exist.  Varicose veins and spider veins are not life-threatening conditions.  Treatment is not mandatory.  Insurances rarely cover the cost of these treatments. 

Some patients get adequate relief of symptoms from wearing graduated support stockings. 

Pulsed Dye and Nd:YAG lasers can be used to treat superficial veins that are 3 millimeters or less in diameter.  PDL’s may cause temporary, dark, purple-red marks called purpura over the areas that were treated. The marks fade in several weeks, but may leave brown discolorations in some patients. 

Other lasers can treat small (1-2mm), superficial vascular and pigmented lesions as well.  Multiple sessions are required for any kind of laser treatment.

Ambulatory Phlebectomy is another method to remove superficial varicose veins under “tumescent anesthesia” in the office.  Tiny (2-3mm) incisions are made every inch or so over the diseased vein.  A tiny instrument is used to hook portions of the vein, tease it out and then excise it.  The next area down is treated similarly.  Steri-strips pull the edges of the incisions together and a compression dressing is applied.

RadioFrequency and Laser tipped catheters can be threaded through the skin into larger, diseased veins that are relatively straight.  This is done with local anesthetic in the office or an out-patient surgery center. 

Surgical stripping or surgically tying off diseased veins may treat large varicose veins.  This procedure is done by a general or vascular surgeon in an outpatient surgical facility or hospital while the patient is under general anesthesia.  Risks of vein stripping are similar to sclerotherapy with the additional risks of the general anesthetic.  General anesthesia has some rare, but serious, associated risks including the possibility of paralysis, brain damage, and death.

Another option is to receive no treatment at all.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

POSSIBLE COMPLICATIONS OF NOT RECEIVING TREATMENT:

In cases of large varicose veins, spontaneous phlebitis (inflammation) and/or thrombosis (blood clot) may occur with the further risk of possible pulmonary embolus.  Chronic swelling and skin breakdown and discoloration may develop around the ankles and lower legs of patients with long-standing varicose veins and underlying venous disease.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

PROPOSED TREATMENT RESULTS:

I know the practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot guarantee results.  While the overwhelming number of patients have noted gratifying symptomatic and cosmetic improvement, specific results cannot be guaranteed.  I also recognize the need and agree to keep Dr. Zimmerman/Dr. Lee and staff informed of any changes in my medical condition and cooperate with them in my after-care, including any changes in my permanent address and phone number.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

CONSENT FOR VEIN SURGERY:

I hereby authorize Dr. Edward Zimmerman and/or associates, to perform Sclerotherapy on me, attempting to improve the symptomatology and/or appearance of my veins.  This make require multiple visits initially and periodic maintenance treatments thereafter.

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

CONSENT FOR ANESTHESIA:

I consent to taking a mild sedative or anxiolytic like Valium or Xanax before my procedure if I want/need it.  (Please advise us if this is something you prefer.  You must have someone available to drive you home if you are medicated.)  I also consent to the use of "local" injectable numbing medicine (LIDOCAINE) during the procedure.  Risks involved with the use of local anesthesia including allergic or toxic reactions and even cardiac arrest (very, very rare).

Patient Initials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

CONSENT FOR PICTURES:

Digital photographs will be obtained periodically for your medical record-to document your initial problems and the results of your therapy over time.  These pictures are kept confidential unless you give permission for their use in advertising or teaching.

INFORMED CONSENT:

By signing below, I acknowledge that I have read the foregoing informed consent form and that I understand the process, purpose, risks and expected results of Sclerotherapy, alternative methods of treatment, and the risks of not treating my condition.

I have had any opportunity to ask any questions and had them answered to my satisfaction.

I hereby consent to vein treatments.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }