CONSENT FOR SCLEROTHERAPY OF VASCULAR LESIONS

DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.

1. I hereby request the above named surgeon and/or his associates to perform a surgical procedure known as Sclerotherapy for telangiectasia (vascular lesions). This procedure has been explained to me by the doctor(s) and I completely understand its nature and consequences.

2. I understand that every surgical procedure involves certain risks and possibilities of complications such as bleeding, infection, poor healing, etc and that these and other complications may follow even when the doctor uses the utmost care, judgment and skill. These risks have been explained to me and I accept them. The following points have been explained in detail.

a. That while a certain amount of improvement is anticipated, the exact amount of change in the appearance of the skin cannot be accurately predicted. Secondary procedures may be necessary to achieve your desired result. Improvement will always be achieved.

b. That during the treatment of telangiectasia, there may be discomfort and swelling following surgery.

c. That the skin will have a reddish appearance which may persist for several days.

d. That in some cases, small inflammatory lesions may appear on the skin.

e. Although infection following sclerotherapy is unusual, bacterial, fungal and viral infections can occur.

3. I recognise that, during the course of the operation, unforeseen conditions may necessitate additional or different procedures than those outlined. I, therefore, further authorise and request that the above-named surgeon or his/her assistants perform such procedures as are, in his or her professional judgment, necessary and desirable. The authority granted under this Paragraph 4 shall extend to remedying conditions that are not known to or could not reasonably be anticipated by the above doctor(s) at the time the operation is commenced.

4. I consent to the administration of local or topical anaesthetic agents by or under the direction and supervision of the above doctor(s).

5. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure; nor are there any guarantees against unfavourable results.

6. I consent to be photographed before, during and after the surgery; that these photographs shall be the property of the above doctors and may be used as they deem proper for scientific and educational purposes.

7. I agree to keep the above doctor(s) informed of any change of address, and I agree to cooperate with them in my care after surgery until completely discharged.

8. I have read a copy of the foregoing consent for the operation, understand it, accept these facts, and hereby authorise the above doctor(s) to perform this surgical procedure on me.

IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING

The patient is a minor of ______ years of age; and we, the undersigned, are the parents or legal guardian of the patient and do hereby consent for the patient.

Parent or Legal Guardian ______________________________________________________________

Witness____________________________________________________________________________

20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile: (02) 9328 6036