I understand that as part of my healthcare, the healthcare providers of 4 You LLC. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. 4 You LLC. Notice of Privacy Practices provides specific information and complete description of how my personal information may be used and disclosed. I understand that a copy of the Notice of Privacy Practices is available at the front desk and understand that I have the right to review the notice prior to signing this consent. I understand that 4 You LLC. reserves the right to change the Notice of Privacy Practices. Prior to implementation of the revised Notice of Privacy Practices, there vised Notice will be mailed to me if I provide my address below. I understand I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that 4 You LLC. is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that 4 You LLC. has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically).
For more information about this notice or our privacy practices and policies, please contact the person listed at the end of this document.

NOTE: 4 You LLC. must obtain your written authorization to use your Private Health Information for any purpose other than treatment or billing. If you want 4 You LLC. to have access to disclose your Private Health Information to your spouse or any other person during your treatment, please sign below.

I, the above named patient, authorize and give my Informed Consent for staff at 4You LLC for the administration of hormone replacement therapy.

Expected Benefits of Hormone Replacement Therapy:

• Control of symptoms associated with declining hormone levels.
• Possible benefits of this therapy may help prevent, reduce or control physical diseases and dysfunction associated with declining hormone levels, through hormonal replacement.
• I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medial community as new, controversial, and unnecessary by the Food and Drug Administration. I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of hormone replacement therapy.

Risks and Side Effects of Hormone Replacement Therapy:

Some of the following risks/adverse reactions are derived from the official Food and Drug Administration “FDA” labeling requirements for these drugs, for therapeutic drug levels in the blood stream. My healthcare provider may prescribe these medications at dosages designed to achieve physiologic levels of hormones in my blood stream or urine generally associated with those of a 20-35 years-old person and would be within the “normal” or “average” blood concentrations of that age group.

Preventative medicine and bioidentical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as medical doctors, nurses, nurse practitioners and/or physician assistants, insurance does not recognize bioidentical hormone replacement as necessary medicine BUT rather more like plastic surgery (aesthetic medicine). Therefore, bioidentical hormone replacement is not covered by health insurance in most cases.

Insurance companies are not obligated to pay for our services (consultations, insertions or pellets, or any other work done through our facility). We require payment at time of service. WE WILL NOT, however, communicate in any way with insurance companies.

This form and your receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, appeal nor make any contact with your insurance company. If we receive a check from your insurance company, we will not cash it but will return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected Health Information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement.

The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

Some of the following risks/adverse reactions are derived from the official Food and Drug Administration “FDA” labeling requirements for these drugs, for therapeutic drug levels in the blood stream. My healthcare provider may prescribe these medications at dosages designed to achieve physiologic levels of hormones in my blood stream or urine generally associated with those of a 20-35 years-old person and would be within the “normal” or “average” blood concentrations of that age group.

General:

I understand that the general risks of this proposed therapy may include, but are not limited to, bruising, soreness or pain, and possible infection for hormones administered by injection.

I understand that there are risks (both known and unknown) to any medical procedure, treatment and therapy, and that it is not possible to guarantee or give assurance of a successful result. I acknowledge and accept these known and unknown general risks.

Risks:

Risk of testosterone replacement include but are not limited to: stimulation of benign and malignant prostate tumor. Testosterone replacement is contraindicated in patients with known prostate cancer.

Side Effects:

Side effects of testosterone replacement may include but are not limited to an increase in the red blood cells, determined by periodic measuring of your red blood. It is not a common occurrence and generally poses no health risk; it can be corrected by donating blood or with a therapeutic phlebotomy. Male pattern baldness, gynecomastia (breast enlargement), diminished sperm production and a reduction in the size of the testicles may develop in men. Testosterone replacement may reduce insulin requirements in insulin-dependent diabetics. Older male patients may be at a slightly increased risk for the development of prostate enlargement when replacing testosterone. The concurrent use of testosterone with corticosteroids may enhance edema (fluid retention) formation. Edema may be a complication with testosterone replacement in patients with pre- existing cardiac, renal, or hepatic disease. It is not known whether testosterone replacement therapy will increase the risk for prostate cancer.

The most common immediate side effects (occurring in approximately no more than 6% of users) include but are not limited to: acne. application site reaction, headache, hypertension (high blood pressure), abnormal liver function tests, and non-cancerous prostate disorder. Other side effects may include greasy hair and skin, a strong body odor, and aggressiveness.

Risks:

Risks associated with estrogen replacement include, but are not limited to: heart attacks, blood clot formation, gallstones, increased risk of uterine cancer (if progesterone is not administered with concurrently) and fibroid tumors. The Women’s Health Initiative study demonstrated increased risk when estrogen replacement is initiated 10 or more years after menopause.

Estrogen replacement is not recommended in women with a history of the following conditions: breast or uterine cancer, phlebitis and blood clots, gall bladder disease, uterine fibroma, and liver disease. If you have a history of any of these disease processes, you may still be considered for hormone replacement therapy, but you must discuss risk vs benefits, as well as quality of life with your provider. You (the patient) must make an informed decision and understand/acknowledge that.

Side Effects:

 Side effects may include, but are not limited to: increased body fat, fluid retention, uterine bleeding, depression, headaches, impaired glucose tolerance, and aggravation of migraines.

Risks:

Risks of progesterone replacement include but are not limited to: Progestins are not the same as natural progesterone. Progestins may cancel the protective effect of estradiol and promote constriction of the coronary arteries to a significant degree. Natural progesterone, on the other hand, may protect the endometrium, preserve the beneficial effects of estrogen on the cardiovascular system and exert no negative effects on the blood vessels that supply your heart. Progestins may cause birth defects, damage to nerve cells, blood clots, and breast cancer.

Side Effects:

May include but are not limited to: nipple or breast tenderness, drowsiness, fluid retention, slight dizziness, anxiety, difficult sleeping, depression, acne, rashes, hot flashes, appetite increases and weight gain.

Risks:

Risks/adverse reactions include but are not limited to: palpitations and rapid heart rate, heart arrhythmias, excitability, increased metabolism. Cardiac sensitivity is a contraindication to thyroid replacement therapy. Excess amounts may increase the risk for osteoporosis in some people and suppress the body’s own ability to manufacture its own thyroid hormone.

Side Effects:

Side effects may include, but are not limited to: sleep disturbances, fine trembling of fingers, excessive hunger and thirst, sweating, anxiety, and headaches.

Risks:

Risks with pregnenolone replacement include but are not limited to: exacerbation of various cancers and should be avoided in those with cancer of the prostate, breast or uterus. Very high doses may cause cardiac arrhythmias.

Side Effects:
Side effects of Pregnenolone replacement may include, but are not limited to: headaches, bloating, menstrual irregularities, heartburn, acne, agitation, sedation, rash and flushing.

I understand the reasonable alternatives to hormone replacement therapy, which include:

• Leaving the hormone levels as they are and doing nothing. Risks may include but are not limited to experiencing symptoms of hormone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining hormone levels. This alternative may result in the need to treat diseases or dysfunction associated with declining hormone levels as they appear clinically.
• Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies. Risks may include but are not limited to increased risk for aging-related diseases resulting from declining hormone levels.

I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting, taking by mouth, applying to my skin, or administrating the hormone(s) that may be prescribed to me, and consent to periodic monitoring, when requested, which may include:

• Laboratory monitoring of blood or urine chemistries and hormone levels
• Physical examinations
• Regular screening evaluations. Patients of 4You LLC must be seen in person every 90 days.

I agree to notify you regarding all signs or symptoms of possible reactions to my therapy.

I agree to comply with all other healthy lifestyle activities that have been individually recommended for me. I have completely disclosed my medical history, including prescription and non-prescription medications that I am currently taking or plan to take during my treatment, as well as any other over-the- counter medications, recreational drugs or social substances, herbs, extracts, and other dietary supplements to you. I agree to comply with the recommendations regarding the continuation of these preparations.

In the future I will receive recommendations in advance from you before stopping any prescribed therapeutic regimens or taking additional preparations that are not recommended by you.

I certify that I am under the care of a physician(s) for any and all other medical conditions outside of hormone replacement therapy.

I understand that the prescribing practitioner is not engaged in any personal research and has no economic interests unrelated to my immediate care or treatment that may affect the physician’s choice of treatment or medical judgment.

I certify that I have been given the opportunity to ask any and all questions I have concerning the proposed treatment, and I received all requested information and all questions were answered. I fully understand that I have the right to not consent to hormone replacement therapy. I believe I have adequate knowledge upon which to base an informed consent.

I do now attest to reading and fully understanding this form and the contents and clinical meanings of such and discussing these procedures with my healthcare provider and consent to this treatment, and hereby affix my signature to this authorization for this proposed long-term treatment. I have been given a copy of this consent form, and I understand fully any and all of the possibly represented implications and meanings of its writing and expectations.

Some services provided at 4You LLC, can be done through TeleHealth and I understand that I am voluntarily engaging in a telemedicine consultation. I understand that I am submitting a health questionnaire that will contain my basic medical history, current symptoms (if any), and goals for treatment that will be reviewed by a licensed medical provider. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the video conferencing connections are not adequate for the situation. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation (if done via video or phone) that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained.

I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided will be limited or not done at all. Telemedicine services offered through 4You LLC, are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care. By signing this form, I certify That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.

This information is for use by the parties named above only, and may not be disclosed to any other individual or agency without the patient’s consent or as otherwise provided by law. This authorization is subject to revocation at any time except to the extent the 4You, LLC has already taken action in reliance on it.

I understand that the information in my medical records may include information related to sexually transmitted disease, AIDS/HIV testing or diagnosis, mental health services, or drug/alcohol abuse diagnosis or treatment, and/or AIDS (Acquired Immunodeficiency Syndrome). Information in the form of audio, photo, or video has been designated above, if applicable.

I understand that 4 You, LLC, Ashley Caldwell, Certified Nurse Practitioner with NPI: 790336741, will not withhold health care if I do not sign this consent, but that exchange of private information with an outside entity such as a future employer or consulting physician will not be made without my consent. A copy of this consent and annotation concerning the persons or agencies with which information was exchanged will be included in my medical records. I understand that health information exchanged under this consent might be redisclosed by a recipient and no longer be protected by privacy laws.