TRT Consent form
Testosterone Replacement Therapy
Informed Consent to Treat
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I hereby give my consent to evaluation and treatment by CLINIC IV DRIP AND BOTOX, Miguel Suarez, FNP-C, APRN, and any other provider associated with CLINIC IV DRIP AND BOTOX for the following specified condition(s):
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Andropause or associated symptoms (Including testosterone replacement, manipulating hormone levels including DHEA and estradiol). Growth hormone abnormalities including decreased or suboptimal IGF -1, decreased or suboptimal Vitamin D-3 levels. Nutritional deficiencies, Overweight/Obesity, B12 injections and anything else the medical provider deems is necessary. I acknowledge that treatment with testosterone, growth hormone stimulators, bioidentical hormone replacement therapy, B12, and thyroid optimization are considered off label use of the associated medications and have not been FDA approved for the use of health optimization, wellness, weight loss and/or for anti-aging purposes unless there is true medical necessity.
I agree to the administration of hormone replacement therapy, and/or nutritional supplements, and/or drugs designed to alter hormone levels which will meet my specific treatment objectives and to treat any specific diagnoses I might have.
Alternative Treatments
I have been informed about alternative treatments and understand:
That we can leave the hormone levels alone.
We can use a natural approach such as weight loss and nutrition instead.
We can use alternative medications to increase your testosterone levels vs using prescription testosterone.
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I understand the alternative treatments and am choosing to consent to the treatment plan prepared for me by CLINIC IV DRIP AND BOTOX to address the condition/conditions listed above.
Side Effects and Potential Risks
I acknowledge that common side effects of testosterone replacement are acne, possible balding, enlargement of the prostate, high blood pressure, high libido, enlargement of breast tissue (we will monitor and treat estrogen levels), testicular atrophy, fluid retention, infertility, and an increase in the thickness of your blood (hematocrit) due to the production of red blood cells (this will be monitored and treated if necessary). I understand that the possible theoretical/possible side effects for men on testosterone replacement can be an acceleration in the growth of prostate cancer, elevations in hematocrit which could potentially predispose one to a blood clot, and cardiovascular disease including heart attacks, strokes, and blood clots. Most of the common side effects resolve with time. Many of these can be treated by changing your testosterone dose and adding other medications. I acknowledge that I should take extreme precaution if I am to use topical testosterone products. If a child or women accidently is exposed to the testosterone cream/lotion on my body it could cause a significant increase in their hormone levels which could result in possible side effects.
Safety of Hormone Replacement
I understand that Available data supports the safety of testosterone replacement therapy in men, and it is of the opinion of CLINIC IV DRIP AND BOTOX and/or Miguel Suarez, FNP-C, APRN, that treatment is safe, but there still remains controversy regarding the correlation between the use of testosterone replacement therapy and cardiovascular events such as but not limited to: strokes, heart attacks, and blood clots. Some studies have shown correlations between testosterone replacement therapy and cardiovascular disease while others show no correlation or even a benefit in preventing cardiovascular disease. I understand that close monitoring is required by all patients to minimize and prevent any possible risks. I understand that CLINIC IV DRIP AND BOTOX will monitor my blood work including hormone levels. I also understand that it is important to stay up to date with routine screening and health maintenance by my primary care provider to prevent and detect any possible life threatening diseases or conditions. I agree to obtain and remain up to date on all age-appropriate screenings including, but not limited to, digital rectal exams, colonoscopies, cardiac screenings, and any other type of recommended health screenings. I agree to obtain these screenings through the direction of my primary care provider and will not hold CLINIC IV DRIP AND BOTOX, Miguel Suarez, FNP-C, APRN, or any additional CLINIC IV DRIP AND BOTOX staff responsible or liable for performing these health maintenance screenings or the treatment of any other conditions not relevant to my treatment goals with CLINIC IV DRIP AND BOTOX. I want to initiate treatment at CLINIC IV DRIP AND BOTOX and I give permission to CLINIC IV DRIP AND BOTOX and Miguel Suarez, FNP-C, APRN and additional staff of CLINIC IV DRIP AND BOTOX to begin treatment without knowing results of age-appropriate and health maintenance screenings. In doing so, I release CLINIC IV DRIP AND BOTOX Miguel Suarez, FNP-C, APRN and other healthcare practitioners of any claims of liability for cardiovascular events, prostate cancer, breast cancer, testicular cancer, and/or colon cancer. Further, I agree to immediately notify CLINIC IV DRIP AND BOTOX, Miguel Suarez, FNP-C, APRN and additional staff of CLINIC IV DRIP AND BOTOX of any abnormal findings on any health screenings done by my primary care provider.
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