State-of-the-art, personalized skin care
from experienced professionals
“A regular skin checkup can literally save your life.” Jennifer Krasnoff, MD

Before the procedure, I have read all of the provided material about the procedure of sclerotherapy.
I understand that the sclerosing agents that may be used for my treatment in this office are hypertonic saline, sotradecol or polidocanol. I acknowledge that adverse reactions may occur which include: allergic reaction, mild systemic reaction (headache/nausea/vomiting) bruising, stinging, transient hyper- or hypo- pigmentation, blistering, superficial ulceration, clot formation, swelling, telangiectatic matting, superficial thrombophlebitis and pulmonary embolism.

I understand that sclerotherapy will not completely eliminate my spider veins, but that after repeated treatments I can expect a 60-80% improvement. It has been made clear to me that optimum results require that I follow the pre- and post-operative instructions (i.e. discontinuing blood thinning agents, wearing compression stockings, daily walking, avoiding hot tubs and vigorous exercise). I do expect that due to the natural healing process, bruising and even reddening of my treated vessels may cause my legs to look worse before they look better.

I understand that there are contraindications for sclerotherapy which include the following instances: previous allergic reaction to injected agent, active thrombophlebitis, active infections, poor circulation, certain diseases of the blood or blood vessels (hypercoagulable states, blood dyscrasias), immobility (or confinement to bed), a history of pulmonary embolus (clot in lung), uncontrolled diabetes or asthma, toxic hyperthyroidism, lung or skin diseases, large abdominal and pelvic tumors, tuberculosis, acute respiratory or skin diseases, lymph edema. Any of these conditions would exclude me from undergoing the procedure of sclerotherapy.

I agree that pre- & post-operative clinical photographs and videos may be taken to monitor my treatment progress and for patient educational purposes. I understand that my identity will be protected.

I certify that I have read and understand the benefits and limitations of sclerotherapy provided to me in the contents of this consent form. I have been given the opportunity to ask the doctor and staff any questions that I have about the procedure, and all of my questions have been answered through the discussion with them. The doctor and office staff have explained the procedure and its alternatives to me, and I both understand and accept the risks involved in this procedure.

Please download this PDF form to sign.





Petaluma Office
165 Lynch Creek Way
Petaluma, CA 94954
 M-F, 8:00am-5:00pm
(707) 762-5531
Fax: (707) 762-5976



Hercules Office
500 Alfred Nobel Dr., Ste. 245
Hercules, CA 94547
M-F, 8:00am-5:00pm
Open Saturday for aesthetic services
 (510) 741-7418
Fax: (510) 741-7456


Billing office
Fax: 510- 741-7493

At Dermatology Associates of the Bay Area, our board-certified dermatologists serve patients at our Petaluma and Hercules offices. We are committed to the highest standards, and we offer a full range of cosmetic, medical, and surgical dermatology procedures, as well as quality skin care products.

Dermatology Associates of the Bay Area
165 Lynch Creek Way | Petaluma, California 94954 | Phone: (707) 762-5531 | Fax: (707) 762-5976
500 Alfred Nobel Drive, Suite 245 | Hercules, California 94547 | Phone: (510) 741-7418 | Fax: (510) 741-7456