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PATIENT INFORMATION AND MEDICAL HISTORY Name: SSN: Full Address: City State Zip Cell Phone: Alternate Phone: Date of Birth: / /19 Age: Email: HISTORY Please circle if you have or have had : Diabetes.

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Related content

Polidocanol versus hypertonic glucose for...
by M Bertanha · 2014 · Cited by 15 — Sclerotherapy is the preferred treatment for some...
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by J Brittenden · Cited by 89 — in addition to foam sclerotherapy in our application...
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Nov 27, 2019 — Form 10-K Summary ... microdermabrasion, sclerotherapy and electrolysis...
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Standard Form 1169 2019 Gsa Form 2529 2005 Gsa Form 12000 April 2011 Fillable 2016 Rwa Form 2015

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Ethanol (alcohol)/ethanol gel Pure ethanol is one of the most effective sclerosing agents in the treatment of venous malformations. The sclerosing effect is based on massive damage to the endothelium with subsequent thrombosis.

To ensure the safest and fastest sclerotherapy recovery, here are four rules you must follow: Wear compression stockings. It is recommended that you wear compression stockings for at least 2-3 weeks after your sclerotherapy treatment. ... Avoid the sun. ... Avoid strenuous exercise. ... Always follow up with your vein specialist.

Drugs used to treat Varicose Veins Drug nameRatingRx/OTCGeneric name: polidocanol systemic Brand names: Varithena, Drug class: sclerosing agents For consumers: dosage, side effects For professionals: AHFS DI MonographExpand current row for information about Varithena VarithenaRateRx13 more rows

Report 36471 for injection of multiple veins on the same leg. If both legs are injected report as follows: One vein on the left, two on the right: 36470 LT and 36471 RT. Injections for each leg should be reported on separate lines.

The most commonly used agents are hypertonic saline, sodium tetradecyl sulfate, polidocanol, and chromated glycerin. Hypertonic saline 23.4% concentration is approved by the US Food and Drug Administration (FDA), but its use in sclerotherapy is off label.

The laws vary by state, but in California, only a licensed healthcare provider such as a Physician, Nurse Practitioner (NP), Physician Assistant (PA), or Registered Nurse (RN) is legally able to perform sclerotherapy.

® (polidocanol) Injection is a prescription medicine that is used in a procedure called sclerotherapy and administered by a healthcare provider to treat two types of veins in your legs.

Sclerotherapy is an injection of an FDA approved medication in either liquid form, or in some cases, as a foam. Common sclerotherapy agents in the united states include Polidocanol and .

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232