CONSENT FOR BIO-IDENTICAL ESTROGEN-PROGESTERONE REPLACEMENT THERAPY (HRT)

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 Estrogen-Progesterone 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 Bio-Identical Estrogen-Progesterone 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 risks of Bio-Identical Estrogen-Progesterone Replacement Therapy. We have a great deal of important information on our website and on the many Bio-Identical Estrogen-Progesterone 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 Bio-Identical Estrogen-Progesterone Replacement Therapy. You should also be aware of all the alternatives to Bio-Identical Estrogen-Progesterone Replacement Therapy, which always include not using Bio-Identical Estrogen-Progesterone 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 Bio-Identical Estrogen-Progesterone Replacement Therapy is the right thing for you. That this is 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 Estrogen-Progesterone 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 Medical doctors and staff, that you are fully ready to start and that you are hereby giving your consent to start on the Advance Wellness West Valley Medical Group Bio-Identical Estrogen-Progesterone 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 Advance Wellness West Valley Medical Group Bio-Identical Estrogen-Progesterone Replacement Program.

2. The risks and benefits of Bio-Identical Estrogen-Progesterone 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 women may develop Acne, if this occurs I will tell the doctors immediately.

4. I have been informed that some women may develop Breast and/or Nipple Tenderness, and possibly even Breast Enlargement, if this starts and/or is a problem I will tell the doctors immediately.

5. I have been informed that some women may experience Mood Swings, Breakthrough bleeding, Sleep Disturbance (Sleep apnea), Nausea, Bloating, Weight Gain or Loss, biliary pathology 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 if I have any history of breast cancer, endometrial cancer, undiagnosed vaginal bleeding, thromboembolic disorders heart attack, stroke (CVA), blood clots, porphyria, severe active liver disease, I should not be using Bio-Identical Estrogen-Progesterone Replacement.

7. I have been informed that I should not smoke cigarettes, pipe or chew tobacco while I am using Bio-Identical Estrogen-Progesterone Replacement as this increases my risk of heart attack, stroke and breast and other types of cancers.

8. I have been informed that in some women Bio-Identical Estrogen-Progesterone Replacement may cause or worsen certain gynecologic problems, for example: fibroids endometriosis, pelvic cramps or pelvic pain, I will tell my doctors if I have any of these conditions immediately.

9. I have been informed that some women may develop changes in cholesterol levels, triglyceride levels. red blood cell levels, and liver function testing and other hormone levels which will be monitored with periodic blood tests.

10. I understand that l will be followed with periodic blood tests in order to monitor my blood hormone levels, kidney and liver functions, hemoglobin and hematocrit. Taking blood tests can be painful and can cause bruising.

11. I understand there is no warranty nor guarantee as to the result of undergoing Bio-Identical Estrogen-Progesterone Replacement Therapy and that my condition may not improve or may even become worse.

12. 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 Advance 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 Estrogen-Progesterone Replacement Therapy and that I must be satisfied with all of their answers as a condition of staying on this program.

13. I understand that the physical exam by Advance Wellness West Valley Medical Group does NOT replace having a full physical exam by my personal physician.

14. I agree to have my personal physician perform a yearly full physical exam including a pelvic exam, pap smear, breast exam, mammography (ultrasound, MRI, CT Scan) lipid profile, and comprehensive metabolic panel (if and when indicated). If l do not have a personal physician Advance Wellness West Valley Medical Group physicians will provide this service.

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