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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 each
statement 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 are
both risks and potential complications to treatment, as well as not being treated. Those risks and
potential complications have been explained to me. I have not been promised or guaranteed any
specific benefit from the administration of these therapies and no warranty or guarantee has been
made regarding the results of treatment. I agree to proceed with treatment and to comply with
recommended dosages.

(Initials) I agree to comply with requests for ongoing testing to assure proper monitoring of my
treatments that may include laboratory evaluation of all hormone levels or other diagnostic testing by a
physician, 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 may
include 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 might
be related to my therapy. I understand that along with the benefits of any medical treatment or
therapies, 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 received
information regarding those risks, potential complications and benefits, and the nature of bio-identical
and other hormone treatments and have had all my questions answered. Furthermore, I have not been
promised 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 physician
evaluation, laboratory tests and pharmacy charges, with the understanding that I may not be
reimbursed 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 to
me. 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 about
hormone replacement therapy, potential complications, required testing, and costs and have had them
answered to my satisfaction. I agree not to undergo any treatments unless I fully understand the
treatment and have discussed possible risks and benefits. I fully understand what I am signing and
hereby request and consent to treatment using bioidentical hormone replacement therapy.

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October 8, 2023 4:15 pm HST

Hormone Replacement Consent Form Uploaded by Lucky Robinson - [email protected] IP 72.234.27.111