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Informed Consent For Sclerotherapy

Consent Forms

Possible Side Effects or Complications from Sclerotherapy Treatment

Every procedure involves a certain amount of risk, and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your medical aesthetic physician to make sure you understand the risks, potential complications and consequences of Sclerotherapy.

  • Ecchymoses (bruises) may be either small or large.  They occur frequently during the course of treatment but should disappear within 3-4 weeks.
  • Tiny red spots will be caused by the injection of varicosities; they disappear within 3 weeks.
  • Tender red cords may develop.  This is not phlebitis.  This occurs occasionally and is usually a temporary inflammation reduced through brisk walking and by applying of warm moist compressors.
  • In rare instances the skin remains a darker colour in some areas and takes longer to regain its normal pigmentation; some spots may take between 2 months to 2 years to disappear and may in some very rare cases be permanent.  It is always important, especially after the first treatment to come for a check-up. 
  • Spider veins may appear after injections of large veins.  The majority will disappear after 4-6 weeks and the remaining few can always be treated.
  • As with all medication, there is always a chance that you may be allergic to the sclerosing agent.  This rare complication can range from a slight tingling sensation and/or red blotches on the skin, to anaphylactic reaction.
  • Another very rare complication is ulcer formation.  It will heal but will unfortunately leave a scar.

In some situations, it may not be possible to achieve optimal results with a single procedure.  Should complications occur other treatments may be necessary. Even though risks and complications occur infrequently, the risks sighted are the ones that particularly associated with anti-wrinkle injections.

Informed Consent

I hereby consent to the treatment of my varicose/superficial veins by Dr Inge van Dyk.

I further consent to receive intravenous sedation if it might be necessary as explained by the said doctor. I realise that the results of my treatment cannot be guaranteed (as with any other medical treatment).

I declare that I am aware of the possible side-effects and complications and that I had the opportunity to discuss them with Dr Inge van Dyk.

Fees: The fees for my treatments have been discussed with me and are acceptable to me. Payment is my own responsibility and refunds from medical aids cannot be guaranteed.

I have read the foregoing consent for the procedure, understand it, accept these facts, and thereby authorize the doctor to perform the procedure of Sclerotherapy.

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