CONSENT FOR PREGNENOLONE 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 Pregnenolone 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 Pregnenolone 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 Pregnenolone Replacement Therapy. We have a great deal of important information on our website and on the many Pregnenolone 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 Pregnenolone Replacement Therapy. You should also be aware of all the alternatives to Pregnenolone Replacement Therapy, which always include not using Pregnenolone 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 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 Pregnenolone 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, and get more answers so that when you decide Pregnenolone 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 Pregnenolone 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 Pregnenolone Replacement supplements as part of my Anti-Aging/HRT Programs.

2_____ . The risks and benefits of Pregnenolone 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 Pregnenolone may develop Acne, Drowsiness, Insomnia Muscle Aches, Headache, Fluid Retention, Rapid, Racing or Irregular Heart Beat, Stomach Upset,. If any of these symptoms occur, I will tell the doctors immediately.

i)_____ . I have been informed that I could experience episodes of over-stimulation, Irritability, Anger, Depression, or Anxiety while using Pregnenolone Replacement, I will tell the doctors immediately.

4_____ . 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.

5_____ . I understand there is no warranty nor guarantee as to the result of undergoing Pregnenolone Replacement Therapy and that my condition may not improve or may even become worse.

6_____ . 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 Pregnenolone Replacement Therapy and that I must be satisfied with all of their answers as a condition of staying on this program.

7_____ . 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.

8_____ . 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 an Advanced Wellness West Valley Medical Group physicians will provide this service.