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La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
416-962-4444
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Our Doctors
Dr. Laura Musselman
Dr. William El Masri
Dr. Lawrence B. Cohen
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Ulthereapy Non-surgical Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Jeunesse FUE Hair Transplant
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction
Body Makeover Surgery
Vaginal Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Day of Surgery COVID-19 Questionnaire & Informed Consent
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Consent for Sclerotherapy of Varicose and Spider Veins
Book Appointment
Name
Date
I hereby authorize La Fontaine Source de Jeunesse 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. 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. 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: 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. Clusters of spider veins (telangiectatic mattes). These small veins often resolve spontaneously, may need treatment in an attempt to clear them, and could be permanent even with treatment. Bruising is common and typically resolves over a few days to weeks. Blistering, redness, itching, irritation, swelling or pain can occur but are usually temporary. Infection is very rare Ulceration and scarring occur rarely. Allergic reactions are rare. They range in severity from mild to life threatening reactions. 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. Deep vein thrombosis (blood clots) and pulmonary embolism (clot in the lungs) are rare. Injury to a nerve, causing either prolonged or permanent discomfort, numbness or difficulty walking is very rare. 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. Other side effects are possible although uncommon. 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. I believe I have sufficient information to give this informed consent. I certify that this information has been explained fully to me, that I have read it or have had it read to me, and that I understand its contents. I voluntarily consent to this procedure. I do not consent to the taking of photographs/videos for use regarding my care as well as for educational or scientific l purposes.
Consent
By initiating this form, I confirm that my answers are true and have been answered to the best of my ability.
Send
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