Sclerotherapy Consent


Procedure:
Sclerotherapy is the injection of medication (“sclerosant’) via a needle into unwanted veins. The goal is to irritate and scar the
veins from the inside such that these abnormal veins close and no longer fill with blood. Several treatments are usually required to obtain maximum improvement. Treatment Options: There are generally no major risks if I elect not to have treatment. I am aware that alternative treatments exist and can include no treatment, compression therapy, surgery to excise the veins, and ablation with laser or radiofrequency.

Benefits:
This procedure may decrease discomfort and other symptoms from leg veins and may provide an improved cosmetic
appearance. I am aware that no available treatment for spider, reticular and/or varicose veins is successful 100% of the time.
Multiple treatments may be required. Treated veins may fail to close or may close and then re-open. Additional or alternative
treatments may be required. Results are not guaranteed. I have discussed and have been given the opportunity to ask
questions about my condition, alternative forms of treatment, risks of non-treatment, the procedures to be used, and the risks
and hazards involved.

Risks:
There are risks and hazards related to the performance of sclerotherapy planned for me. I realize that complications can occur and include but are not limited to these listed below:
1. Brownish discoloration. This is not uncommon but is usually temporary. It could take several months or longer to resolve. It is uncommon for discoloration to be permanent.
2. Clusters of spider veins (telangiectatic mattes). These small veins often resolve spontaneously, may need treatment to clear them, and could be permanent even with treatment.
3. Bruising is common and typically resolves over a few days to weeks.
4. Blistering, redness, itching, irritation, swelling or pain can occur but are usually temporary.
5. Infection is very rare
6. Ulceration and scarring occur rarely.
7. Allergic reactions are rare. They range in severity from mild to life threatening reactions.
8. Inflammation around a vein can occur. This may be tender but generally resolves with treatment. Tenderness, bruising or
firmness in the treated area can occur and may be long lasting but rarely permanent.
9. Deep vein thrombosis (blood clots) and pulmonary embolism (clot in the lungs) are rare.
10. Injury to a nerve, causing either prolonged or permanent discomfort, numbness or difficulty walking is very rare.
11. An arterial injection can occur very rarely. Consequences range from discomfort, scarring of the skin, injury to muscle or
nerves or other tissue, or loss of limb.
12. Other side effects are possible although uncommon.

I hereby authorize Ampika’s Aesthetics and associates/assistants and other healthcare providers he/she deems necessary, to
treat my Right / Left leg varicose and/or reticular and/or spider veins using sclerotherapy.

I understand that my condition is not life or limb threatening. I have been informed of potential consequences of my condition,
ranging from the cosmetic appearance of veins, leg discomfort and swelling to possible leg ulcer development. I also recognize that venous disease is a chronic disorder, and that new vein problems may develop over time, which may require further treatment.

I consent to acting as a model for the purpose of training (under supervision) in the administering of Sclerotherapy. The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had the opportunity to have all my questions answered to my satisfaction. I have answered the questions regarding my medical history to the best of my knowledge.

Training course times may be delayed due to unforeseen circumstances. It may take longer training the students or the student may need more support. So please allow extra time in case this event occurs. Your full payment for your treatment as a model is non-refundable. If the circumstances occur outlined above and/or cancellation your payment is non-refundable. The full payment will be made prior to attending the training academy.

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 practitioner to ensure you understand the risks.


I consent to Ampika’s Aesthetics using photographs being stored on a training file and be used for social media purposes photographs and/or video recordings including images of me both internally and externally to promote the Training Academy. These images could be used in print and digital media formats including print publications, websites, e-marketing, posters banners, advertising, film, social media, teaching and research purposes. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that some overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides. I understand that some images or recordings may be kept permanently once they are published. I have read and understand the conditions and consent to my images being used as described.

I am signing to consent to my treatment being administered at Ampika’s Aesthetics. On behalf of the training academy Ampika’s Aesthetics - Ampika’s Hair Make Up and Beauty. You are agreeing to be a model and hold no responsibility towards Ampika’s Aesthetics for any procedures that may incur any personal dissatisfaction or cause of concern.

Any models wishing to seek any legal or liable action will not be permitted to do so once signing this disclaimer you are excepting full responsibility to allow a student to carry out your injectable treatments. These Students who are responsible for carrying out the treatment under medical supervision, are not fully qualified to carry out Sclerotherapy unassisted. Therefore, you understand the risk that this may pose. Any concerns must be addressed whilst you are present in the training academy. Whilst all the trainers accommodate you to ensure you are fully satisfied with your treatment, we are unable to rectify problems weeks after you have undergone the treatment. If there are any concerns, then please contact the training academy within 48 hours of treatment via email at [email protected]

By signing this form you have agreed to consent to adhere to our vaccination policy.

I consent I have read and understood the aftercare sheet which has been provided to me

The information that I have given is correct to the best of my knowledge.

I have not knowingly withheld any medical information.

I consent to the treatment described.

 

 

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Signed by Ampika Pickston
Signed On: March 24, 2021

Signature Certificate
Document name: Sclerotherapy Consent
lock iconUnique Document ID: ead609e04af6a1ef08be1db6974c70b4686b69d9
Timestamp Audit
November 23, 2020 11:15 am BSTSclerotherapy Consent Uploaded by Ampika Pickston - [email protected] IP 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8
February 1, 2021 9:49 am BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:c553:e3b7:94b6:6079
March 24, 2021 2:24 pm BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8