CONSENT FOR MELATONIN REPLACEMENT THERAPY

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 Melatonin 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 Melatonin Replacement 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 Melatonin Replacement Therapy. We have a great deal of important information on our website and on the many Melatonin Replacement Therapy 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 Melatonin Replacement Therapy. You should also be aware of all the alternatives to Melatonin Replacement Therapy, which always include not using Melatonin Replacement 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 your self aware and decisively think about all of this, ask all the questions you need answers so that you can be entirely sure that using Melatonin Replacement Therapy is the right thing for you, if this is right time and 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 Melatonin 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 West Valley Medical Group 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 Melatonin 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 use Melatonin Replacement supplements as part of my Anti-Aging/HRT Programs.

2_____ . The risks and benefits of Melatonin Replacement Therapy has been explained to me and I fully understand that occasionally there are complications associated with this treatment.

3_____ . I have been informed that some man and women may develop Headaches, Drowsiness, Insomnia. If any of Increased Dreaming, or Nightmares. If any of these symptoms occur, I will tell the doctors immediately.

4_____ . I have been informed that some men and women may experience minimal to significant Depression. If any of these symptoms occur, I will tell the doctors immediately.

i)_____ . I have been informed that I could experience episodes of mood wings, Irritability, Anger, Depression, or Anxiety, Weight Gain while using Melatonin Replacement. If any of these symptoms occur, I will tell the doctors immediately.

5_____ . I have been informed that some men and women may develop High Blood Pressure or 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.

6_____ . 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.
7_____ . I understand there is no warranty nor guarantee as to the result of undergoing Melatonin Replacement Therapy and that my condition may not improve or may even become worse.

8_____ . 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 Melatonin Replacement Therapy and that I must be satisfied with all of their answers as a condition of staying on this program.

9_____ . I understand that the physical exam by Advanced Wellness West Valley Medical Group does NOT replace having a full physical exam by my personal physician.

10_____ . I agree to have my personal physician perform a yearly full physical exam including for women, 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 a Advanced Wellness West Valley Medical Group physicians will provide this service.

Patient                                                            Date

Witness                                                         Date