These forms must be read and understood before the treatment of Schlerotherapy will be conducted. Please note that our office policy requires cancellations at least 48 hours in advance. Issuing your signature below indicates that you have read and understood these documents and understand the risks and office requirements of this procedure.

Pre-Treatment Instructions

Post-Treatment Instructions

Consent to Schlerotherapy Treatment

Lucencia Medical Cancellation Policy

  • Consent to Treatment

    My digital signature below indicates that I have received, printed or downloaded a copy of the pre-, post-, consent and refund policy forms found above and that my doctor has adequately informed me of the risks of sclerotherapy treatment, alternative methods of treatment, and the risks of not treating my condition. I have fully read, understood and agree to the content of these documents, and my electronic signature below represents my signed consent to sclerotherapy treatment. Additionally, I agree to the refund and cancellation form in its entirety, and agree to pay Lucencia Spa in case of cancellation that takes place less than 48 hours in advance.
  • Date Format: MM slash DD slash YYYY
  • Optional Information

    The information below is optional and not required for form submission. Entering your e-mail address will sign you up for occasional promotion emails and newsletters from Orlando Heart Specialists, Lucencia Medical Spa, and Center for Vein and Vascular. We will never sell your information.