Bioidentical Hormone Replacement Therapy (BHRT) Informed Consent Form Logo

  • Bioidentical Hormone Replacement Therapy (BHRT) Informed Consent Form

    This consent form outlines the agreement between the patient and Aspire Medical Group regarding the use of Bioidentical Hormone Replacement Therapy (BHRT) as part of the patient’s treatment plan. It is important for patients to understand the benefits, risks, and responsibilities associated with BHRT to ensure safe and effective treatment. The following information is intended to educate the patient about the risks and benefits of BHRT and facilitate informed consent.

  • Indications for Bioidentical Hormone Replacement Therapy (BHRT)

    BHRT is indicated for individuals experiencing symptoms due to hormonal deficiencies or imbalances, such as:

    - Menopause
    - Surgical menopause
    - Andropause
    - Polycystic Ovary Syndrome (PCOS)
    - Premenstrual Dysphoric Disorder (PMDD)
    - Other hormonal disorders

    Treatment Description

    BHRT involves the use of hormones that are chemically identical to those produced by the human body. These hormones are derived from plant sources and are customized to meet individual patient needs.

    Potential Benefits

    The potential benefits of BHRT may include:

    - Relief from menopausal or andropausal symptoms (e.g., hot flashes, night sweats, mood swings)
    - Improved energy levels and mood
    - Enhanced libido and sexual function
    - Better sleep quality
    - Prevention of osteoporosis

    Potential Risks and Side Effects

    As with any medical treatment, BHRT carries potential risks and side effects. These may include, but are not limited to:

    - Breast tenderness
    - Bloating
    - Weight gain
    - Mood changes
    - Increased risk of blood clots
    - Cardiovascular disease
    - Stroke
    - Breast cancer

    Safety Precautions

    1. Initial and Regular Monitoring: Blood tests and other diagnostic tools will be used to assess hormone levels before starting therapy and regularly throughout treatment to ensure appropriate dosing and safety.

    2. Personalized Dosing: Hormone dosages will be tailored to meet individual needs and will be monitored closely to avoid overdosing or underdosing.

    3. Comprehensive Medical History: A thorough review of your medical history will be conducted to identify any contraindications or potential risks.

    4. Ongoing Communication: Regular follow-up appointments will be scheduled to monitor your progress and address any concerns or side effects.

    5. Emergency Contact: Immediate medical attention is required if you experience symptoms such as severe headaches, chest pain, shortness of breath, or vision changes. In emergencies, call 911 or visit the nearest emergency room.

    Alternative Treatments

    You may consider the following alternative treatments to BHRT:

    1. Lifestyle modifications (e.g., diet, exercise, stress management)
    2. Non-hormonal medications
    3. Conventional hormone replacement therapy

  • FDA Disclaimer

    Bioidentical Hormone Replacement Therapy (BHRT) involves the use of compounded hormones, which are considered off-label by the U.S. Food and Drug Administration (FDA). This means that BHRT has not been specifically approved by the FDA for the treatment of any medical condition. The use of bioidentical hormones is based on clinical experience and is considered an alternative treatment option. As with any medical treatment, BHRT should be discussed thoroughly with your healthcare provider to determine if it is appropriate for you.

  • Age Disclaimer

    Bioidentical Hormone Replacement Therapy (BHRT) is intended for adult patients only. You must be 18 years of age or older to undergo BHRT. By signing this consent form, you confirm that you meet the minimum age requirement for this treatment.

  • Patient Acknowledgment and Consent

    By signing this form, I certify that:
    • I have informed my healthcare provider of all my medical conditions, known allergies to drugs or other substances, and any past adverse reactions I have experienced. I have also informed my provider of all medications and supplements I am currently taking.
    • I understand that the bioidentical hormone replacement therapy (BHRT) prescription is compounded and not FDA-approved. However, I have been informed that the compounding pharmacy is FDA-monitored, and the medication is third-party tested. I am aware of the possible side effects and understand that this medication could be harmful if taken inappropriately. I agree to use this medication only as prescribed.
    • I acknowledge that no guarantees have been made to me regarding the results of this treatment.
    • I will inform my provider if I become pregnant or am breastfeeding during the course of treatment.
    • I release Aspire Medical Group from any and all liability related to my receipt of the bioidentical hormones.
    • I consent to the use of bioidentical hormones as part of my treatment plan. I understand that my treatment with these medications will be governed by the terms of this agreement. I accept the risks, conditions, and terms outlined in this document.
    • I am signing this form voluntarily and confirm that I have the full legal right and authority to be bound by this agreement. I agree to comply with the terms of this policy. By signing this form, I voluntarily give my consent for treatment and accept the associated risks.

  • Electronic Signatures

  • By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

    The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.

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