Left Phlebectomy Right Bilateral Leg Saphenous Vein Stripping With Saphenectomy Consent Form With Powered With Greater Saphenectomy - PDF Document

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  1. Left Phlebectomy Right Bilateral Leg Saphenous Vein Stripping With Saphenectomy Consent Form With Powered With Greater Saphenectomy Patient Name: Guardian Name (if applicable): MY PROCEDURE I hereby give my consent for Dr. or his/her associates to perform a Left Stripping With Powered Phlebectomy Greater Saphenectomy upon me. I understand the procedure is to be performed at the First Hill Surgery Center. This has been recommended to me by my physician in order to diagnose and/or treat varicose veins. I understand that the procedure or treatment can be described as follows: Removal of the saphenous vein through small incisions, removal of varicose veins using a powered phlebectomy device (Trivex). This procedure requires anesthesia. Either general or spinal anesthetic are appropriate; your anesthesiologist will help determine which is most appropriate for you. MY BENEFITS Some potential benefits of this procedure include:  Relief of symptoms associated with superficial venous reflux and elimination of prominent varicose veins. While saphenous vein stripping and powered phlebectomy is often an effective test/treatment for varicose veins and superficial venous insufficiency, not all conditions, diseases or problems can be diagnoses or treated solely by saphenous vein stripping and powered phlebectomy. MY RISKS I understand that there are potential risks, complications and side effects associated with any surgical procedure. Although it is impossible to list all of them, I have been informed of some of the possible risks, complications and side effects of this procedure. These could include but may not be limited to the following:  Bleeding, infection, wound healing problems, clot development in the leg veins, skin ulcerations. Some of these risks, complications and side effects are not serious or do not happen frequently. Although these risks, complications and side effects may occur only very rarely, they do sometimes occur and cannot be predicted or prevented by the physician performing the procedure. Date of Birth: Patient ID: Washington State law guarantees that you have both the right and the obligation to make decisions regarding your health care. Your physician can provide you with the necessary information and advice, but as a member of the health care team, you must participate in the decision making process. This form acknowledges your consent to treatment recommended by your physician. 1 Right Bilateral Leg Saphenous Vein With Saphenectomy With Left Right Bilateral 2 3 Page 1 of 2

  2. MY CONSENT Although most procedures have good results, I understand that no guarantee has been made to me about the results of this procedure or the occurrence of any risks, complications and side effects. I recognize that during the course of treatment, unforeseeable conditions may require additional treatment or procedures. I request and authorize my physician and other qualified medical personnel to perform such treatment or procedures as required. I have chosen to undergo this procedure after considering the alternative forms of diagnosis and/or treatment for my condition including no treatment or other procedures or tests. Alternatives to this procedure may include, but are not limited to compression stocking therapy, endovenous saphenous vein ablation with/without stab phlebectomy, and injection sclerotherapy. These alternative forms of diagnosis and/or treatment have their own potential risks, benefits and possible complications. 4 I certify that I have read or had read to me the contents of this form. I have read or had read to me and will follow any patient instructions related to this procedure. I understand the potential risks, complications and side effects involved with the proposed Left Right Bilateral Leg Saphenous Vein Stripping Powered Phlebectomy With Saphenectomy and have decided to proceed after considering the possibility of both known and unknown risks, complications, side effects and alternatives. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction. I consent to the above procedures as deemed necessary or appropriate by my physician or credentialed provider. With Saphenectomy With Greater Patient Signature: ________________________________ Date: ______ Time: ________ Patient is unable to consent because _______________________. I therefore consent for the patient. Authorized Consenter’s Signature: ______________________________ Date: _______ Time: ______ Printed Name: ______________________________ Relationship to Patient: ____________________ Mark this box if telephone consent Witness Name: __________________________________________________________ PRINT NAME Witness Signature: _____________________________ Date: ________ Time: _____ By my signature below I attest to the fact that I explained the procedure to the patient. Physician Name: _______________________________________________________ PRINT NAME Physician Signature: ____________________________ Date: ______ Time: _____ Page 2 of 2