I, the undersigned, authorize and give my Informed Consent to Advanced Wellness West Valley Medical Group, Inc. and Allen Lawrence, M.D. for the administration of Human Growth Hormone (HGH) Replacement Therapy.
Indications and Expected Benefits of Human Growth Hormone Replacement Therapy:
Risks and Human Growth Hormone Replacement Therapy:
Side Effects of Human Growth Hormone Replacement Therapy:
Alternatives to Human Growth Hormone Replacement Therapy:
I am totally and completely satisfied with my understanding of the reasonable alternatives to HGH replacement therapy, which include:
My Compliance Obligations While Receiving Human Growth Hormone Replacement Therapy:
I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting the HGH prescribed to me, and consent to periodic monitoring when requested, which may include:
Research and Economic Interests:
I understand that neither Advanced Wellness West Valley Medical Group nor Allen Lawrence, M.D. are engaged in any professional research nor do they have any economic interests unrelated to your immediate care or treatment for the problems you have presented with. The use of HGH is yours and your physician’s choice of treatment based on medical judgment and medical judgment alone, no economic interests.
I certify that I have been given the opportunity to ask any and all of the questions I have concerning the proposed treatment, and that I have received all of requested information and all questions were answered to my satisfaction. I fully understand that I have the right to not consent to HGH hormone replacement therapy, and that I have the right to stop it at any time I desire. I believe I have adequate knowledge upon which to base an informed consent.
I do now attest to reading and fully understanding this form and the contents and clinical meanings of such, and having discussed these procedures with my health care provider, and consent to this treatment. I hereby affix my signature to this authorization for this proposed long-term treatment. I have been given a copy of this consent form, and I understand fully any and all of the possibly represented implications and meanings of its writing and expectations.
Patient (Print Name):
Patient Signature: __________________________________________ Date: ______________
Physician Signature: ________________________________________ Date: ______________