Microsclerotherapy Consent Form
Please view below a copy of the Consent Form that you would be required to sign before undergoing this treatment:
Please carefully read and sign this consent form prior to undergoing treatment. By signing this consent form you confirm that you have received sufficient information about microsclerotherapy and have had the opportunity to ask any questions about the treatment. You are also confirming that you understand all the implications of this treatment.
It has been explained to me that:
- There may need to be ongoing treatment and that there is no guarantee as to the success or outcome of this treatment.
I understand that:
- there may be some discomfort following the procedure. Redness and itch are common following microsclerotherapy but will normally resolve within 24hrs.
- increased pigmentation of the skin may occur in up to 30% of cases. This is most often due to the deposition of the pigment melanin and will fade in 6 months. However, in some clients an iron containing pigment, haemosiderin, is deposited in the skin and this may persist for months or even years.
- matting may occur in 20% of cases. This is the development of many tiny red vessels around the injected vessel following microsclerotherapy. If this occurs most cases will resolve within 12 months. Laser treatment can be used to treat resistant cases.
- there is a risk of ulceration of the skin which can occur if some of the sclerosant leaks out of the injected vein into the skin and this complication is much more likely to occur if microsclerotherapy is attempted on small varicose veins around the ankles.
- other complications of microsclerotherapy are extremely rare, but include the development of deep venous thrombosis, pulmonary embolus and even anaphylactic shock if there is an allergic reaction to the sclerosant.
- that I may request a chaperone during my consultation, examination, or treatment.
- unless I specifically request to the contrary, my treating physician may contact my GP or consultant about my progress whilst undergoing treatment and take photographs as appropriate to add to my client record.
- I should follow the aftercare advice issued to me by my treating physician.
- I have been offered a copy of this consent form.