Sclerotherapy Consent Form

"*" indicates required fields

Patient Information

Patient Name*

Informed Consent for Sclerotherapy

The purpose of this procedure is to diminish unsightly spider veins. The procedure may require more than one treatment and may produce permanent vein removal. The total number of treatments will vary between individuals. On occasion there are patients that do not respond to treatments. The procedure involves injecting a solution directly into a vein, causing the treated vein to seal shut and fade from view over time.

The treated blood vessel (vein) is then naturally resorbed by the body, small varicose veins, also known as reticular veins, are small blood vessels that measure between 1 to 3mm in diameter and are also known as feeder veins. Small varicose veins can enlarge as a result of increased pressure in the vein or from weakened vein valves. You may have only small varicose vein and spider veins at the same time.

Some factors that may increase your risk of developing them:

  • Hereditary: If other family members had varicose veins, there's a greater chance that you will too.
  • Age: The risk of varicose veins increases with age. Aging causes wear and tear on the valves in your veins that help regulate blood flow. Eventually, this causes the valves to allow some blood to flow back into your veins where it collects instead of flowing up to your heart.
  • Gender: Women are more likely to develop the condition. Changes in hormones due to puberty, pregnancy, menopause, or taking birth control pills may increase a woman's risk of developing varicose veins.
  • Pregnancy: During pregnancy, the volume of blood in your body increases. This change supports the growing fetus but also can produce an unfortunate side effect - enlarged veins in your legs. Hormonal changes during pregnancy may also play a role.
  • Extra weight or obesity: Carrying extra weight eon put additional pressure on the veins. Prolonged standing or sitting may also hinder the healthy flow of blood.

Other possible causes for varicose veins are ethnicity, posture. occupation, hormones such as estrogen and progesterone, primary valvular incompetence, and incompetent perforating veins.

Pre-Treatment Instructions

Please review the following pre-treatment instructions to ensure you are adequately prepared for your sclerotherapy session 1 Week Prior to Treatment

  • Avoid blood thinning substances and supplements or medications such as Aspirin, Ibuprofen, vitamin E and omega-3s to decrease risk of bruising or bleeding.
  • Purchase medical-grade compression stockings for your treatment to optimize results. We recommend 20-30 mm Hg which can be purchased at The Natural Place. You will need to bring the stockings with you to each visit.
  • Do not use bronzers or tanning lotions on your legs.

The Day of Treatment

  • Shower the morning of the treatment (do not shave your legs the morning of sclerotherapy).
  • Do not use body lotion, oils or self-tanners the day of treatment.
  • Bring loose-fitting shorts to wear during the procedure.
  • Bring your medical-grade compression stockings to be worn home (compression of legs will accelerate healing, reduce swelling & bruising). The injections will not be done if you do not bring the stockings with you on the day of treatment.
  • Eat a light meal or snack 90 minute before treatment.

Post-Treatment Instructions

After treatment, compression bandages or stockings are placed on the legs to prevent the formation of blood clots; these should be worn continuously for the 36 hours following treatment. Walking is encouraged after treatment—you should walk immediately following your session and incorporate walks into your daily routine for the following week. Strenuous activity, in addition to long periods of sedentary activity, should be avoided in the first week following your sclerotherapy session.

IMMEDIATELY FOLLOWING TREATMENT

  • Wear compression stockings continually for 36 hours after the procedure (day and night).
  • Continue to wear compression stockings during the day for the next 7 days (put stocking on the morning before you get out of bed and take off just before going to bed).
  • Avoid strenuous physical activity including high-impact aerobics, running and weight lifting for 72 hours.
  • Avoid blood thinning medications (see pre-treatment instructions) for 48 hours.
  • Avoid warm baths, hot tubes and saunas for one week.
  • Avoid flying for one week.
  • Do not expose treated area to sun, tanning bed or self-tanners (this may lead to post-operative pigment changes) for one month after treatment.
  • Walking is very important after your sclerotherapy. We recommend taking a 30 minute walk at least two times a day for the next seven days.
  • May resume usual activity one week after treatment.

GENERAL

  • Expect to have mild pain, bruising, tenderness and swelling at the injection site for the first 24 hours after treatment. Use ice-packs and Tylenol for pain relief.
  • Often times, the veins will look worse after treatment before they look better. The discoloration typically fades in 2-3 weeks.
  • Occasionally, when treating larger vessels, a small dark and lump “knot” may develop due to entrapment of blood in the closed vessel (which is a normal response to the treatment). This will be evacuated by the physician at the time of your next treatment session if necessary.

It is important to closely follow the aftercare instructions provided to you by the TNP Med spa. If you experience significant pain, redness, swelling, crusting or bleeding, call the office at 303-404-0255 opt.1.


Tips for after your procedure:

Wear compression stockings or support hose continuously for up to 3 days and 2 to 3 weeks after treatment during the daytime, walk 15 to 20 minutes right after the procedure and every day for the next few days, Avoid heavy exercise, sunbathing, long plane flights, and hot baths or saunas for 2 to 3 day. Not an actual patient, for optimal safety), doctors recommend you not fly for two or to three days following an Asclera treatment. Also avoid heavy exercise, sunbathing, hot baths, hot tubs and saunas.

Spider Veins/Sclerotherapy (3month): Take all your usual medications the day of your Sclerotherapy unless otherwise instructed. Wear loose fitting clothing and comfortable shoes to accommodate the compression stockings. You may brag shorts to wear for your treatment if you would be now comfortable. Shower the morning of your Sclerotherapy. Do not use moisturizer on your legs. Do not shave your legs on the morning of your Sclerotherapy. Please remember to bring your compression stockings if you have them, and or purchase of them are available at desk. Avoid tanning your legs for approximately 1 month before and for at least 1 month after your treatment. Use heavy sunscreen if you are in the sun. ALL TREATMENTS MUST USE SPF 45/50 Before and After Treatments.

The following complications may occur with the Sclerotherapy vein removal system:

  1. Risks: I understand there is a risk of bruising, burning sensation/pain, blood clots, allergic reaction, hyperpigmentation and temporary cramping. These side effects usually take 1-4 weeks to heal, however pigmentation irregularities can take up to six months to heal.
  2. Infection: Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.
  3. Effectiveness: While now veins may appear over time, I understand removal can be permanent.
  4. Treatments: I understand removal of veins will take several treatments we recommend Follow-up 4 weeks from initial treatment; your may be required to take supplements such as B-complex & Varicosity Vitamins to help strengthen vein site. Also do know some candidates might need compression garments to help achieve desired results.
  5. Allergic Reactions: If rare cases, there may be an allergic reaction to the sclerosing solution.
  6. There is a risk of scarring.
  7. I will l follow all aftercare instructions as it is crucial I do so for healing.

Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

I have read, initialed, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily, I understand this procedure and accept all risks and will notify TNP of any changes that could put my treatment at risk. I hereby release The Normal Place, Dr. Copeland, Dr. Buford & Bridget Hahn and staff from all liabilities associated with the indicated procedure

Name
Signature Date*
This field is for validation purposes and should be left unchanged.