This document is intended to serve as confirmation of informed consent for Hormone Replacement Therapy & Wellness Management as ordered by The Q Institute’s in-house physician, Mark Zhuk, MD.
I have received counseling about my current health status, the proposed treatment and related risks. This form contains a brief summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I understand I may refuse consent and I GIVE MY INFORMED AND VOLUNTARY CONSENT to the proposed therapies and other matters shown below. I also consent to further appointments and treatments and understand that through the course of my therapy they are to be in my best interests and that delays might impair my health.
I authorize Mark Zhuk, MD of The Q Institute to treat my condition, including performing further diagnosis and the treatments described below.
I understand the purpose to be: Hormone Replacement Therapy & Wellness Management.
I also understand that there may be risks or complications or serious injury from therapies provided from known and unknown causes. I am aware that the practice of medicine and Hormone Replacement Therapy & Wellness Management is not an exact science and I acknowledge that no guarantees have been made to me concerning the risks of the therapies.
By initiating a course of HRT, your medical provider is using his or her best judgement in recommendations for you and there is no guarantee of an outcome.
I understand that if I wish not to accept the risks associated with this therapy, then the alternative would be to not sign this consent.
I have informed the physician of any known allergies to drugs or other substances, or of any past reactions to medications and medical history. I have informed the physician of all current medications and supplements.
PATIENT CERTIFICATION
By signing below I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the consents of this form. I understand the information on this form and give my consent to what is described above and to what has been explained to me.