Z Medi Clinics and Z Medi Spa
CONSENT TO HORMONE REPLACEMENT THERAPY
Purpose: I hereby authorize practitioners with this clinic to provide medical care to me, including but not limited to hormone replacement therapy. I recognize that if I am diagnosed with a hormone deficiency or, in the opinion of my healthcare practitioner, exhibit an increased risk allaying a hormone deficiency that bio-identical hormone replacement therapy may be recommended. I have been advised that some of the bio-identical hormone preparations that may be prescribed for me are regulated by the pharmacy compounding laws. I understand that the use of this therapy may be debated in the traditional medical community. Treatment Regime: I have been advised that the practitioners with this clinic generally advise and prescribe bioidentical hormone supplementation to restore normal levels. Commonly used treatments involve estrogen, progesterone, and testosterone, thyroid hormones, cortisol, and anti-oxidants. Apart from hormones, Vitamin D and other compounds may be used to stimulate my body’s own hormone production. I understand that these treatments require that I follow dosage and instructions exactly, and I agree to do so. I understand that the therapies may include the use of drugs regulated by the US Drug Enforcement Agency (DEA) as controlled substances.
Risks: I understand that hormone replacement therapy carries potential risks and benefits. Risks of this program may include but are not limited to bloating, breakthrough bleeding, breast swelling and tenderness, fluid retention, weight gain, liver cysts, mood swings, death from blood clots or cancer, increased risk of cancer, (estrogen) missed menstrual cycles, sedation, depression (progesterone) acne, chronic priapism (persistent, abnormal erection of the penis), change in libido, angina or heart attacks, hirsutism (facial hair growth) and scalp hair loss, clitoral engorgement, voice changes, improved insulin resistance, skin irritation, and increased risk of diabetes. Certain estrogen formulations have been associated with an increased risk of breast cancer and blood clots. Because it may improve insulin resistance in males, diabetics who use insulin should monitor glucose levels closely, as less insulin may be needed. Check with your physician before adjusting your dose of insulin. If using a formulation of testosterone that is applied to the skin, a local irritation may occur. In women, excessive testosterone, or DHEA doses could increase the risk of diabetes or facial hair. With any hormone therapy, notify your healthcare provider if you are pregnant, suspect that you have become pregnant, or if you are planning to become pregnant.
Benefits: Bio-identical hormone replacement therapy is implemented to optimize hormone levels in the body, as determined by physical examination and appropriate testing. The therapy helps to reduce symptoms associated with low levels of certain hormones, including estrogen, progesterone, and testosterone. Inadequate and imbalanced hormones levels are associated with fatigue, weight gain, joint Pain, and poor libido. Replacement therapy is intended to mitigate these issues.
Consent to treatment by a physician extender: You may be evaluated and treated by a physician assistant (P.A.) or a nurse practitioner (N.P.) whose recommended care and treatment is subject to supervision and review by a licensed physician.
I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN SATISFACTORY EXPLAINED TO ME. WITH MY SIGNATURE I ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED FULLY, AND THAT I HAVE BEEN REQUESTED TO READ THIS FORM AND HAVE BEEN GIVEN AMPLE TIME TO UNDERSTAND ALL ITS CONTENTS.