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Varithena direct order form

Use this form to place an order for a Varithena product.

*All fields required unless noted below.

Account Name

Account Number

PO #

Contact First Name

Contact Last Name

Email address

Phone Number

Shipping Street Address

Shipping City

Shipping State

Shipping Zip Code

VARITHENA Canister Quantity

VARITHENA Canister, Product #FP00019 Varithena Canister Special Instructions:

VARITHENA Admin Pack Quantity* (minimum order quantity of 3 is recommended when ordering admin packs)

VARITHENA Admin Pack, Product #FP00024 Varithena Admin Pack Special Instructions:

Authorized by (Full Name)

Please note:
State and local sales taxes apply in certain states. Orders submitted after 1:30pm CT will be processed the next business day. For order questions, call: 855-971-8346 (VEIN). All orders for Varithena are shipped ground and can take up to 5 business days to arrive to you.

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Indications

Varithena® (polidocanol injectable foam) is indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein (GSV) system above and below the knee. Varithena® improves the symptoms of superficial venous incompetence and the appearance of visible varicosities.

Important Safety Information

The use of Varithena® is contraindicated in patients with known allergy to polidocanol and those with acute thromboembolic disease. Severe allergic reactions have been reported following administration of liquid polidocanol, including anaphylactic reactions, some of them fatal. Observe patients for at least 10 minutes following injection and be prepared to treat anaphylaxis appropriately. Intra-arterial injection or extravasation of polidocanol can cause severe necrosis, ischemia or gangrene. Patients with underlying arterial disease may be at increased risk for tissue ischemia. If intra-arterial injection of polidocanol occurs, consult a vascular surgeon immediately.Varithena® can cause venous thrombosis. Follow administration instructions closely and monitor for signs of venous thrombosis after treatment. Patients with reduced mobility, history of deep vein thrombosis or pulmonary embolism, or recent (within 3 months) major surgery, prolonged hospitalization, or pregnancy are at increased risk for developing thrombosis. The most common adverse events observed were pain/discomfort in extremity, retained coagulum, injection site hematoma or pain, common femoral vein thrombus extension, superficial thrombophlebitis, and deep vein thrombosis.Physicians administering Varithena® must be experienced with venous procedures, possess a detailed working knowledge of the use of the duplex ultrasound in venous disease and be trained in the administration of Varithena®.

See Full Prescribing Information for Varithena®

PI-1263705-AA