Consent for Testosterone Replacement Therapy (TRT)

AGELESS HEALTH INNOVATIONS

Consent for Testosterone Replacement Therapy (TRT)
Patient Name

First NameLast Name
SOME THINGS YOU SHOULD KNOW ABOUT TESTOSTERONE REPLACEMENT THERAPY

It is important to understand that medicine is an inexact science. Although we plan and carry out our treatment as carefully as we can, the results can vary in their degree of success. It is only natural for a patient undergoing Testosterone Replacement Therapy to want to be reassured that everything will turn out alright. Most of the time it will, but most of the time isn’t all the time, so it is necessary to talk about what can go wrong.

In the “old days,” physicians and nurses did not always inform their patients about all of the risks of certain treatments because they didn’t want their patients to worry about things that they felt were their responsibility. But now it is very important that you be aware of the risks involved and actively participate in the decision of whether to begin treatment. You should be aware of the potential risks as well as the potential benefits expected from the treatment. You should also be aware of the alternatives to testosterone replacement therapy, which always include not doing the treatment. We cannot promise you a good result because it is impossible to deliver that every time, but we can promise you our best efforts.

It is very important that you think about all of this, ask questions, and be sure that you feel that you are doing the right thing, at the right time, with the right doctor – if you’re not sure, then you should wait. Please now go on to the following pages, which discuss informed consent. Any questions that you might have should be brought to my attention. I will attempt to answer all of your questions to your satisfaction.

DIRECTIONS: INITIAL EACH STATEMENT AFTER YOU READ IT IF YOU AGREE WITH WHAT THE STATEMENT SAYS.
1. This is my consent for AGELESS HEALTH INNOVATIONS, with any physician or nurse who is working with the company, to begin treatment for testosterone deficiency, weight management, IV Fluid, vitamin therapy e.g. B12, or other treatment provided.
blanks 2. It has been explained to me and I fully understand that occasionally there are complications of this treatment. Can be as followed:
blanks 3. Acne.
4. Breast Enlargement.
5. Mood Swings.
6. Extra fluid in the body. This can cause problems for patients who have heart, kidney, or liver disease.
7. Sleep disturbance. This is called sleep apnea and is more likely in patients who have lung disease or are overweight.
8. Prostate Enlargement which may cause problems with urinating.
9. Changes in cholesterol levels, red blood cell levels, PSA levels, and liver function enzymes, and other hormone levels which will be monitored with periodic blood tests.
10. I understand that testosterone replacement therapy may increase complications and adverse outcomes, including death, for those with known heart disease. If I am under 65 with known heart disease I must be cleared by a Cardiologist or my primary care provider. If I am 65 years or older, with or without known heart disease, I must be cleared by a Cardiologist or my primary care provider.
11. 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.
12. The use of testosterone products may lead to blood clots in the veins, Venous Thromboembolism VTE, and Deep Vein Thrombosis DVT.
13. I understand there is no warranty or guarantee as to the result and that my condition may return or become worse.
14. I have had an opportunity to discuss with AGELESS HEALTH INNOVATIONS and its medical practitioners my complete.
Copyright AGELESS HEALTH INNOVATIONS, 2022. All rights reserved. Not authorized for further reproduction or distribution without written permission from AGELESS HEALTH INNOVATIONS

Ageless Health Innovations

Consent for Testosterone Replacement Therapy (TRT)
Past medical and health history including any serious problems and/or injuries. All of my questions concerning the risks, benefits, and alternatives have been answered. I am satisfied with their answers.
15. I understand that the physical exam by AGELESS HEALTH INNOVATIONS does NOT replace a full physical exam by a personal physician.
16. I agree to have my personal physician to perform a yearly full physical exam including a digital rectal exam, lipid profile, cholesterol levels, and a comprehensive metabolic panel. If I do not have a personal physician AGELESS HEALTH INNOVATIONS will assist in locating one for me.
17. FERTILITY - I understand that the use of exogenous testosterone may result in testicular atrophy as well as lowering of my sperm count that can diminish my fertility/ability to father a child while on therapy and for an indeterminate time into the future.
18. Certain medical authorities recommend HCG to be given twice weekly to minimize testicular atrophy and to increase fertility/ability to father a child.
19. I understand that normal ranges for testosterone are generally established by reference to morning levels and that men’s testosterone levels generally decline in the afternoon.
20. I understand that men’s testosterone levels can vary significantly between tests, even when the tests are conducted at the same time of day.
21. I understand that the AGELESS HEALTH INNOVATIONS treatment protocol recommends testosterone replacement therapy if I have a total testosterone level of less than 400 nanograms per deciliter, 430 nanograms per deciliter and certain symptoms, or 600 nanograms per deciliter if my free testosterone is below 11 nanograms per deciliter. I also understand that according to the Endocrine Society Guidelines, the threshold for testosterone replacement therapy should be in the range of 200 to 300 nanograms per deciliter.
22. I understand that certain medical guidelines, including the Endocrine Society Guidelines and the guidelines of the American Urological Association, state that blood tests for the purposes of diagnosing hypogonadism should be performed in the morning and that two morning tests should be performed before starting patients on TRT. The Mayo Clinic consensus guidelines and our own AGELESS HEALTH INNOVATIONS protocol do not include such a recommendation.
Patient Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Physician Name
Date

MonthDayYear
Date
Witness Name
Date

MonthDayYear
Date
Should be Empty:

AGELESS HEALTH INNOVATIONS

Ageless Health Innovations