CONSENT FOR BIO-IDENTICAL AND TESTOSTERONE HORMONE REPLACEMENT THERAPY (TRT)

It is important to understand that medicine is an inexact science. Although we desire, plan and carry out our treatment as carefully as we can, the results can often vary in their degree of success. It is only natural for a patient undergoing Bio-Identical Testosterone Replacement Therapy to want to be reassured that everything will turn out alright. Most of the time it does, but most of the time isn’t all the time, so it is necessary to talk about what can go wrong.

It is your responsibility to be aware of the risks and benefits of using testosterone for medical treatment and ours to make sure you understand fully and correctly. If you have questions that are not answered within this Consent Form please ask us so that you will have a complete and clear understanding of both the benefits and the risk of Testosterone Replacement Therapy. We have a great deal of important information on our website and on the many Testosterone Treatment Handouts we have already given you and it is important that you have read them and are fully aware of all of the risks involved so that you can actively participate in the decision as to whether you will begin Testosterone Replacement Therapy. You should also be aware of all the alternatives to Bio-Identical Testosterone Replacement Therapy, which always include not using testosterone at all. While we cannot promise you perfect result, as it is impossible to deliver perfect every time, we can promise you our best effort in working with you to attain all of your desired results.

It is vital that you spend time making yourself aware and decisively think about all of this, ask all the questions you need answers so that you can be entirely sure that using Testosterone Replacement Therapy is the right thing for you. That this is the right time and that you are working with the right doctors and staff to attain your hormonal goals and needs – if you’re not sure, still have questions or need help then you should wait, ask more questions, get more answers so that when you decide Bio-Identical Testosterone Replacement Therapy is right for you, it is right for you.

After you have reviewed this informed consent, after you have asked all of questions you needed answers to, then signing this consent tells both you and our Advanced Wellness doctors and staff, that you are fully ready to start and that you are hereby giving your consent to start on the Advanced Wellness West Valley Medical Group Bio-Identical Testosterone Replacement Therapy/Anti-Aging Program. By signing this Informed Consent form you are stating that you are fully ready to start and that you have asked and received appropriate answers to all of your questions and you are ready to start now.

Read each statement below, if you understand and agree with what the statement says, initial that statement:

1_____ .      I hereby give my consent to start the Advanced Wellness West Valley Medical Group Bio-Identical Testosterone Replacement Program.
2_____ .      The risks and benefits of Bio-Identical Testosterone Replacement have been explained to me and I fully understand that occasionally there are complications associated with this treatment.
3_____ .      I have been informed that some men may develop Acne, if this occurs I will tell the doctors immediately.
4_____ .       I have been informed that some men may develop Gynecomastia (breast tenderness, nipple swelling and/or breast enlargement), if this starts to or is occurring I will tell the doctors immediately.
5_____ .      I have been informed that some men may develop Mood Swings, Sleep Disturbance (Sleep apnea), experience possible weight gain, and possibly Edema (extra fluid in their body which can cause problems for patients who have heart, kidney or liver disease).
6_____ .      I have been informed that some men may develop Prostate Enlargement (Benign Prostatic Hypertrophy) which may cause problems with urinating as well as Prostate Specific Antigen (PSA) blood level changes.
7_____ .      I have been informed that some men may develop changes in cholesterol levels, red blood cell levels, and liver function testing and other hormone levels which will be monitored with periodic blood tests.
8_____ .      I understand that l will be followed with periodic blood tests to monitor my blood hormone, kidney, liver, hemoglobin and hematocrit, PSA levels and that taking blood tests can be painful and can cause bruising.
9_____ .     I understand there is no warranty nor guarantee as to the result of undergoing Bio-Identical Testosterone Replacement Therapy and that my condition may not improve or may even become worse.
10 . I understand that l have the opportunity to discuss my complete past and present medical and health history including any serious medical conditions I suffer with the Advanced Wellness West Valley Medical Group practitioners and that I can ask all of the questions that concern me regarding the risks, benefits, and alternatives associated with Bio-Identical Testosterone Replacement Therapy and that I must be satisfied with all of their answers as a condition of staying on this program.

11_____ .     I understand that the physical exam does Advanced Wellness West Valley Medical Group does NOT replace having a full physical exam by my personal physician.
12_____ .     I agree to have my personal physician perform a yearly full physical exam including a digital rectal exam, lipid profile, and comprehensive metabolic panel (if and when indicated). If l do not have a personal physician a Advanced Wellness West Valley Medical Group physicians can upon request provide this service.

Patient____________________________________________  Date  ____________

Witness___________________________________________ Date  _____________