lifecareforwomen.com - HTCA Consent Acknowledgement Form

HTCA Consent & Acknowledgement Form
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CONSENT FOR HORMONE IMPLANTATION
1. I authorize my practitioner, to perform the following procedure: STERILE PLACEMENT OF HORMONE PELLETS UNDER THE SKIN.
2. I understand the reason for the procedure is hormone replacement therapy using Estradiol and/or Testosterone.
3. RISKS: Risks that may be associated with this particular including bleeding, infection, and/or pellet extrusion.
4. LOCAL ANESTHESIA: The administration of anesthesia also involves risks; most importantly, a rare risk of reaction to medication causing death. I consent to the use of such anesthetics as may be considered necessary by the medical professional, physician or practitioner responsible for these services.
5. I understand that no guarantee or assurance has been made as to the results of the procedure and that it may not cure any condition I may have.
6. PATIENT'S CONSENT: I have read and fully understand this consent form and understand I should not sign this form if all items, including my answers, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form.
7. PROVIDER'S DECLARATION: I have explained the contents of this document to the patient and have answered the patient's questions, and to the best of my knowledge, I feel the patient has been adequately informed and consented.
Please sign here to consent to cancellation and liability information *

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HTCA Consent & Acknowledgement Form

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