Please list any medications you are currently taking including vitamins and dietary supplements

Are you currently experiencing any of these symptoms:

If you need bloodwork, we charge a bloodwork fee of $200 (Includes blood draw and Dr consultation) before we order your labs.  There will be a charge for the Dr consult if you provide all labs requested by Endless Vitality. ***I authorize Endless Vitality to charge my credit card and keep my card on file for future payments, to include payments for a monthly treatment plan of my choice, automatically charged each month while signed up for the program as we dispense medication. At any time, I would have the option to discontinue my program. I understand that I need to notify Endless Vitality to cancel further monthly credit card charges prior to meds being dispensed.

Testosterone Replacement Therapy Consent

Here at Endless Vitality, we believe that the best care and results are achieved through a trusting relationship between patient and provider. Our treatments are specifically tailored to each individual as we believe a cookie cutter approach to medicine is a great disservice to all involved. The success of each patient will be affected by numerous factors. These include, but are not limited to: genetics, adherence to the prescribed regimen, careful follow up, open and free dialogue with their provider, epigenetic factors, and close monitoring of their labs/progression.

We believe in full disclosure concerning complications that might arise from hormone/testosterone treatments.

Your complete understanding of potential risks is vital for a trusting rapport with your provider. All treatment options, including deciding not to undergo any therapy at all, are open to you as a patient. As providers, our mission is to inform you of potential risks and benefits thereby enabling you to make the best informed decision possible for achieving your individual short and long term goals.

The following points will cover your informed consent. Any questions regarding the following points will all be addressed to your satisfaction before initiating any treatment regimen.

2. I fully understand that complications may arise from these treatments including -Acne: large pimples or cysts that can arise anywhere on the body usually the trunk -Breast Enlargement: may be irreversible in a small number of patients - Mood Swings: Getting angry or sad for no apparent reason Fluid Retention: Extra fluid building up in the body which can be especially dangerous to patients with heart disease (CHF), kidney disease, and liver problems - Sleep Disturbances: Most commonly sleep apnea, which is more likely in patients who have lung disease or who are overweight - TRT does not increase the risk for prostate cancer, however TRT will stimulate an existing prostate cancer. BloodClots:Usually in the veins called venous thromboembolism (VTE) or deep venous thrombosis (DVT) which are more serious including difficulty breathing or death - Changes in cholesterol levels, red blood cell levels, Prostate Specific Antigen (PSA) levels, liver function enzymes (AST/ALT), and other hormone levels which will be monitored during treatment with periodic blood tests.  I understand that testosterone replacement therapy may increase complications and adverse outcomes, including death, for those with known heart disease and I must be cleared by my cardiologist before starting therapy. If I am 65 years or older, with known heart disease, I must be cleared by a Cardiologist before starting any therapy.

4. I understand that I will have periodic blood tests to monitor my blood levels and that this can be painful and leave bruises on the skin.

5. I understand there is no warranty or guarantee as to my individual results and that my condition may return or become worse when on therapy or after stopping therapy.

6. I understand that the physical exam by Endless Vitality and its physicians/nurses does NOT replace a full physical exam by my primary care physician.

7. I agree to have my primary care physician perform an annual full physical exam including a digital rectal exam (males) and any/all yearly blood work as well as all age appropriate cancer screenings. If I do not have a primary care physician Endless Vitality will assist me in locating one.

The Patient accepts and agrees to the following: - I understand that the medication(s) I have purchased are prescribed to me based on diagnosis derived from my submitted medical history, lab work and physical exam. They are to be based exclusively for treatment of these diagnoses. -I will immediately report any adverse side effects related to the use of my medication to Endless Vitality and discontinue use until advised to resume usage. -I will safeguard my medications from loss or theft. -I will not share, sell or trade my medication for money, goods or services. -I agree that I will use my medication at the prescribed rate and dosage. -I will not attempt to obtain scheduled HRT 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 have had an opportunity to discuss all of the above items with Endless Vitality and its medical practitioners. I have also informed them of my complete past medical health and surgical history including ALL serious problems and/or injuries. All of my questions have been answered in full and I understand each point I have initialed above. All of the risks, benefits, and alternatives to testosterone replacement therapy have been answered fully.

Statement of Patient Responsibility in submitting my health information (symptoms, conditions, comments, answers to questions, and fully completed Health Information form) in connection with my request for services, the following statements are true: 1.  I am an adult at least 18 years of age or older. 2. I am competent to use the services offered by the third party vendor and I fully understand the material presented to me. 3. I voluntarily choose to seek a medical provider consultation through the third party vendor. 4. I recognize that the consulting medical provider reviewing my health information may or may not prescribe treatment based on my responses. 5. I am aware that my failure to provide truthful, accurate and complete information to the consulting medical provider and any other providers could result in an inappropriate treatment decision that could be harmful to me or not be safe and effective. Therefore, I have responded or will respond to each question truthfully and accurately. I fully and completely disclose any and all information concerning my health and medical history that could be relevant to my current condition and need for treatment and/or medication. 6. I have seen a medical provider and had a physical examination and/or medical history evaluation within one year of requesting services from the third party vendor. I agree to undergo a physical examination every year to ensure that my request for treatment is appropriate and to inform my personal physician about the products ordered or purchased from the third party vendor. 7.I will contact my physician if I have questions, difficulties, or complications with the recommended treatment. 8. I will make the medical provider aware of any changes to my medical condition in the event I return to the third party vendor seeking services or products of any kind. 9. I understand that I will be given the opportunity to ask any and all questions about any tests, procedures, or medication(s) that may have been prescribed for me. 10. If paying by credit or debit card, I am the owner of that credit or debit card.

PATIENT AGREEMENT AND ACKNOWLEDGEMENT

As a customer or potential client of the services provided by or through the third party vendor, I hereby understand, accept, and agree to the following: 1. I am voluntarily providing my health and medical information for the purposes of obtaining services through the third party vendor. 2. I realize that the medical provider will not conduct an in-person physical examination and will rely on the truthfulness and accuracy of the information I am providing to the third party vendor staff and/or during a telemedicine consultation. 3. I understand that a medical provider who is currently licensed in the United States will review my health information. Therefore, I agree that all online consultations, diagnoses, and treatments will be deemed to have occurred in the state where the consulting medical provider is licensed to practice. 4. I am under the care of a personal physician and I do not consider the medical provider to be my personal primary care physician. 5. I hereby release the third party vendor and medical provider and other employees from any and all claims that the physician acted below the requisite standard of care on the basis that the medical provider did not personally examine me. 6. I hereby acknowledge that all information and services provided by or through the third party vendor are provided "as is" without warranty of any kind expressed or implied.

To our patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA Our commitment to your privacy).

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information to use and Disclosure of Your Health Information in Certain Special Circumstances.

The following circumstances may require us to use or disclose your health information:

1.To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement official. 4.When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosure to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7.To correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement official. 8. For Workers Compensation and similar programs.

Your rights regarding your health information:

You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operation. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment forcare, your suchas family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I have the right to review the Notice of Privacy Practices prior to signing this consent. Endless Vitality and its providers reserve the right to revise this Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Endless Vitality Privacy Officer at 1845 E Broadway Rd Suite 116 Tempe, AZ 85282.

With my consent, Endless Vitality and it providers and staff may call my home or to other designated location and leave a message on a voice mail or in person in reference to any items that assist the practice in carry out TPO; such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others.

TPO, With my consent, Endless Vitality and its providers and staff may mail to my home or other designated location any items that assist the practice in carrying out such as appointment reminder cards and patient statements as long as they are marked personal and confidential.

By this form, I am consenting to Endless Vitality providers and staff to use and disclosure of my Personal Health Information to carry out treatment, payment signing and healthcare operations. I have also read the Notice of Privacy Practices.

I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not sign this consent, Endless Vitality may decline to provide treatment to me.

I herby acknowledge that I have been presented with a copy of Endless Vitality Notice of Privacy Practice

(check all that apply) regarding care and follow up.

The best telephone numbers(s) to reach me are:

I want relevant medical information shared with the person who may answer the

telephone. The name(s) of the individual(s) with whom you may leave pertinent information are:

I want relevant medical information (i.e. lab results, biopsy results) on my answering machine or voicemail

I hereby authorize Endless Vitality to access your medical/ medication history from third party sources (i.e. pharmacies).

I understand that I am consenting to an elective treatment/procedure/surgery that is not urgent or emergent.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that my doctor listed below has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that even if I have received a negative COVID-19 test result, the test may have failed to detect the virus, or may have become infected after I took the test. I understand that even if I do not have any symptoms, I may have a COVID-19 infection, and that having the electivetreatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that exposure to COVID-19 before, during, and after my treatment may result in the following: a positive COVID-19 diagnosis, extended isolation, additional tests, and hospitalization, up to and including: the need for treatment in intensive care (ICU), short-term or long-term intubation, other complications, and death.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that this elective treatment may put me at increased risk for becoming infected with COVID-19. By consenting to this consent form, I accept that risk and give my permission to proceed with treatment.

I have been given the choice to have my treatment at a later date. I understand the potential risks of delaying and want to proceed.

I have read this consent or someone has read it to me.

 

FOR OFFICE USE ONLY:

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because:

•  Individual refused to sign

•  Communication barrier prohibited obtaining the acknowledgement

•  An emergency situation prevented us from obtaining acknowledgement

•  Other (please specify)

 

 

 

 
 

 

HIPAA Officer Date