New Customer Application Forms


Use one of the following forms to create a new customer account with Varithena.

New Customers not licensed in the state of Florida

Use only the Business Application and Letter of Affiliation (LOA) form below.  Business Application: This is the main document to set up a direct account with Varithena.  Letter of Affiliation: (LOA): This document provides authorization to ship Varithena product to the address listed on the form

Business Application & LOA



New Customers licensed in the state of Florida

Use only the Business Application and Declaration of Intention (DOI) form below. Business Application: This is the main document to set up a direct account with Varithena. Declaration of Intention (DOI): This document provides authorization to ship Varithena product to the address listed on the form for residents of Florida

Business Application & DOI 




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®