Sclerotherapy Consultation and Consent Form | Aesthetics Forms Portal

Sclerotherapy Consultation and Consent

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you taking any medication? *

Please list: *

Do you have any allergies? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do any of the following apply to you? Please tick all that apply.

Prolonged bleeding disease Connective tissue disease Arterial disease Diabetes Immune-compromised state Heart/Kidney/Liver disease History of keloid formations Previous adverse reaction to Sclerotherapy Previous blood clot

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

What are your concerns? *

What are your goals and expectations of the treatment? *

Have you previously received treatment for varicose veins? *

What were the results? *

Treatment Information

How does Sclerotherapy work?

In sclerotherapy the salt solution is injected through a very fine needle directly into the vein. At this point, you may experience mild discomfort and cramping for one to two minutes, especially when larger veins are injected.

The procedure itself takes approximately 15 to 30 minutes.

The number of veins injected in one session depends on the size and location of the veins, as well as the general medical condition of the patient.

What to Do Before Sclerotherapy

Prior to sclerotherapy, you should avoid certain medications. Talk to your doctor about all medicines (including over-the-counter drugs, herbs, and dietary supplements) you are taking. If you need to take an antibiotic before sclerotherapy, contact your doctor. No lotion should be applied to the legs before the procedure. Some doctors recommend avoiding Aspirin, Ibuprofen, or other anti-inflammatory drugs for 48-72 hours before sclerotherapy. Paracetamol, however, should not affect this procedure.

Side Effects of Sclerotherapy

You may experience certain side effects after sclerotherapy. There are milder effects, such as itching, which can last for one or two days after the procedure. Also, you may experience raised, red areas at the injection site. These should disappear within a few days. Bruising may also occur around the injection site and can last several days or weeks.

Other Sclerotherapy Side Effects Include:

Larger veins that have been injected may become lumpy and hard and may require several months to dissolve and fade.
Brown lines or spots may appear at the vein site. In most cases, they disappear within three to six months, but they may also last indefinitely.
Neovascularization -- the development of new, tiny blood vessels -- may occur at the site of sclerotherapy treatment. These tiny veins can appear days or weeks after the procedure, but should fade within three to twelve months without further treatment.

Should any of the following side effects occur, contact your doctor immediately. These include:

Inflammation within five inches of the groin
A sudden onset of a swollen leg
Formation of small ulcers at the injection site

Aftercare Advice

After sclerotherapy you will be able to drive yourself home and resume your regular daily activities. Walking is encouraged.You will be instructed to wear support hosiery to "compress" the treated vessels. If you have compression hosiery from previous treatments, you are encouraged to bring them with you to be certain they still have adequate compression. Department store support stockings will not be adequate if a heavy compression stocking is needed. Your practitioner can recommend where to purchase heavy compression stockings.

Following the injections, avoid aspirin, ibuprofen, or other anti-inflammatory drugs for at least 48 hours. Paracetamol may be used if needed.

You should avoid the following for 48 hours after treatment:

Hot baths
Hot compresses
Whirlpools or saunas
Direct exposure to sunlight

Please tick the box to confirm: *

I have read and understood the aftercare advice provided.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the practitioner and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Sclerotherapy treatment.

Client Signature: *

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