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 (Low Testosterone)
    • 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 OF BHRT

    • Relief from menopausal or andropausal symptoms (e.g., hot flashes, night sweats, mood swings)
    • Improved energy, stamina, and mental clarity
    • Better sleep quality
    • Enhanced libido and sexual function
    • Improved skin tone and hair growth
    • Prevention of osteoporosis
    • Improved mood and emotional well-being

  • POSSIBLE RISKS AND SIDE EFFECTS

    As with any medical treatment, BHRT carries potential risks and side effects, including but not limited to:
    • Acne or oily skin
    • Hair thinning or increased facial/body hair
    • Mood swings or irritability
    • Breast tenderness or spotting
    • Headaches
    • Water retention or bloating
    • Weight gain
    • Changes in menstruation
    • Increased red blood cell count
    • Changes in cholesterol levels
    • Cardiovascular disease, stroke
    • Hormone-sensitive cancers (data remains inconclusive)

  • SAFETY PRECAUTIONS

  • 1. Initial and Regular Monitoring: Blood tests and other diagnostic tools will be used before and during therapy to assess hormone levels and ensure safe, effective dosing.

    2. Personalized Dosing: Hormone doses will be tailored to individual needs and adjusted as needed.

    3. Comprehensive Medical History: A full review of the patient’s history will be conducted to identify any contraindications.

    4. Ongoing Communication: Patients agree to attend follow-up appointments and notify their provider of any side effects or changes in health.

    5. Emergency Symptoms: Call 911 or seek immediate medical attention for chest pain, shortness of breath, vision changes, or severe headaches.

  • PREGNANCY AND BREASTFEEDING 

    BHRT is not recommended during pregnancy or while breastfeeding. I agree to notify Aspire Medical Group immediately if I become or plan to become pregnant. 

  • ALTERNATIVE TREATMENTS

    Patients may consider:
    • Lifestyle modifications (e.g., diet, exercise, stress management)
    • Non-hormonal medications
    • Conventional hormone replacement therapy
    • No treatment

  • FDA DISCLAIMER

    Bioidentical hormones used in BHRT may include compounded medications. These are not specifically FDA-approved for all uses but are commonly used in clinical practice and are compounded by pharmacies monitored by the FDA and third-party tested.

  • AGE REQUIREMENT

    BHRT is available to adult patients only. You must be 18 years or older to undergo this treatment.

  • PATIENT ACKNOWLEDGMENT AND CONSENT

    By signing this form, I certify that:
    • I have disclosed all medical conditions, allergies, and current medications/supplements.
    • I understand that some BHRT medications are compounded and not FDA-approved, and I will use them only as prescribed.
    • I have been informed of potential risks, benefits, and alternatives.
    • I understand no guarantees have been made regarding treatment results.
    • I will notify my provider if I become pregnant or begin breastfeeding.
    • I release Aspire Medical Group from liability related to the use of bioidentical hormones.
    • I understand that therapy requires compliance with all recommended follow-up appointments, lab testing, and reporting of symptoms.
    • I agree to notify Aspire Medical Group of any changes in my health status, new symptoms, or medication changes.
    • I understand that failure to comply with medical instructions may result in discontinuation of BHRT.
    • I give my informed, voluntary consent to receive BHRT and accept the risks and terms outlined.

  • ELECTRONIC SIGNATURE AGREEMENT

    By providing my electronic signature below, I agree to the use of electronic records and signatures. I acknowledge that electronic signatures (including scanned copies or PDFs) are legally binding.
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