Mammogram Waiver Form

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We follow the American Cancer Society Guidelines for mammograms:
➢ Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so.
➢ Women age 45 to 54 should get mammograms every year.
➢ Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening.
➢ Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
➢ All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening.

I understand the above stated recommendations for mammogram screening. My treating Provider has discussed the importance of a mammogram according to the guidelines.

Although evidence supports the many health benefits of Estradiol, my treating Provider has informed me that exposure to Estradiol in any form could possibly stimulate an undetected cancer, causing growth of and/or reoccurrence(s) of cancerous tissue.

Mammogram completed in last 2 years?

Any abnormal results with mammogram?

Describe abnormal results

Please put NA if not applicable

For today’s appointment I DO NOT have a mammogram for the following reason:

I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk. I voluntarily choose to undergo implantation of subcutaneous hormone pellet therapy.

I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or breast, uterine or cancer issues) that may be sustained by me in connection withmy decision to not have a mammogram and undergo hormone pellet therapy including, without limitation, any cancer that could develop in the future, whether it be deemed a stimulation of a current
cancer or a new cancer.

I hereby release and agree to hold harmless 4You LLC and any of their physicians,
nurses, Nurse practitioner, owners, officers, directors, employees and agents from any and all liability, claims, demands and actionsarising or related to any loss, property damage, illness, injury or accident that may be sustained by me as
a result of a breast cancer diagnosis in conjunction with Estradiol hormone pellet therapy.
I acknowledge and agree that I have been given adequate opportunity to review this document and to
ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

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