Patient Consent Form

Acknowledgement & Consent

I have received a certified copy of Sydney Vein Clinic - Treatment Information Booklet

I have read and understood the Sydney Vein Clinic - Treatment Information Booklet © 2011.

Proposed treatment is _______________

The TREATING DOCTOR has adequately informed me of all the material risks associated with treatment, alternative methods of treatment and the risks of not treating my condition.

Serious risks include _______________

I shall attend all follow-up appointments and adhere to the special precautions in my case and report any problems immediately.

All my questions relating to my disease and the proposed treatment have been answered to my satisfaction.

The proposed treatment plan has been adequately explained to me and I have signed the ‘NSVC Fees Acknowledgement’ form.

Although foam is used and recommended world wide it has not yet been approved by the TGA for use in Australia. I approve of its use in my case within the guidelines set by the European Consensus 2003 and the Australian New Zealand Consensus 2004.

I hereby consent to treatment performed by the TREATING DOCTOR.