This agreement established guidelines and conditions required for the use of hormone replacement (HRT) involving DEA "controlled" or "scheduled" medications. 

These guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and therefore, these agents are prescribed with caution.

 

The patient accepts and agrees to the following conditions:

1. I understand that the medications I have been prescribed are based upon diagnosis derived from my submitted medical history, lab work, and physical examination. They are to be based exclusively for treatment of these diagnoses.
2. I will immediately report any adverse side effects related to the use of my medication to Advanced Practice Clinic and discontinue use until advised to resume usage by one of our clinic practitioners.
3. I will safeguard my medications from loss or theft.
4. I will not share, sell, or trade my medications.
5. I agree that I will use my medication at the prescribed rate and dosage, and will keep the medication in its respective labeled container.
6. I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is against the law to do so.

I also agree that while I am a patient of Advanced Practice Clinic, I will not take any type of anabolic steroids, testosterone gels, hormone "boosters", pre-hormones, or any additional testosterone supplementation not prescribed by Advanced Practice Clinic practitioners during my treatment plan. At any time, if use of these items is discovered, I understand that I may be discharged as a patient of Advanced Practice Clinic.