Hormone Replacement Consent Form
Blessed Hands IV Hydration & Wellness Clinic LLC
Hormone Replacement Therapy & Bio-Identical Hormone Replacement Therapy Patient Consent Form
Please read and review this consent form and ask questions for clarification if needed. Then, initial eachstatement indicating understanding and agreement, and sign at the bottom of the form.
Statement of Patient: (Initials) I understand that along with the benefits of any medical treatment or therapies, there areboth risks and potential complications to treatment, as well as not being treated. Those risks andpotential complications have been explained to me. I have not been promised or guaranteed anyspecific benefit from the administration of these therapies and no warranty or guarantee has beenmade regarding the results of treatment. I agree to proceed with treatment and to comply withrecommended dosages.
(Initials) I agree to comply with requests for ongoing testing to assure proper monitoring of mytreatments that may include laboratory evaluation of all hormone levels or other diagnostic testing by aphysician, my primary care physician, or other specialist. I agree to see my primary care physician,gynecologist, or other practitioner for regular monitoring and for preventative measures that mayinclude but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG,mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc.
(Initials) I agree to immediately report to my physician any adverse reaction or problem that mightbe related to my therapy. I understand that along with the benefits of any medical treatment ortherapies, there are both risks and potential complications to treatment, as well as to not being treated.Those risks and potential complications have been explained to me and I agree that I have receivedinformation regarding those risks, potential complications and benefits, and the nature of bio-identicaland other hormone treatments and have had all my questions answered. Furthermore, I have not beenpromised or guaranteed any specific benefit from the administration of bio-identical hormone therapy.
(Initials) I have been informed that insurance companies may not pay for physician evaluation,laboratory testing, and medications. I therefore agree to pay for all services including physicianevaluation, laboratory tests and pharmacy charges, with the understanding that I may not bereimbursed by my insurance company.
(Initials) I certify this form has been fully explained to me, that I have read it or have had it read tome. I have been educated on the benefits, risks, and possible adverse reactions associated with bio-identical hormone replacement therapy. I have been given the opportunity to ask any questions abouthormone replacement therapy, potential complications, required testing, and costs and have had themanswered to my satisfaction. I agree not to undergo any treatments unless I fully understand thetreatment and have discussed possible risks and benefits. I fully understand what I am signing andhereby request and consent to treatment using bioidentical hormone replacement therapy.
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Document Name: Hormone Replacement Consent Form
Agree & Sign