Bioidentical Hormone Replacement Therapy (BHRT) - Informed Consent

Introduction & Commitment 
At Good Day Pharmacy, we are committed to helping you achieve optimal hormone balance through personalized BHRT therapy. To begin, a $50 non-refundable deposit is required to ensure you are fully committed to this journey.

✅ This deposit secures your place in our BHRT program and is applied toward your first appointment. ($250 less the $50 deposit)

BHRT is a step-by-step, personalized process, and Kelley, our BHRT Master Certified Consultant, will guide you through every stage.

 

Your 6-Step BHRT Journey

1️⃣ Complete Your Symptom Questionnaire
Fill out a comprehensive form detailing your symptoms, medical history, and concerns. This step helps Kelley establish a baseline and determine if BHRT is the right fit for you.

2️⃣ Complete Your Lab Testing
Once Kelley reviews your paperwork, you’ll receive an email from Kelley directing you how to order labs.  We use 2 modalites to measure, saliva test kit mailed to your home ($119-279) and blood tests, which you may already have from recent medical visits. This crucial lab work provides the information needed to create a personalized treatment plan.

3️⃣ Consultation with Kelley
After your lab results are analyzed, Kelley will send you an email to schedule a 1-hour consultation (virtual or in-person at our Loveland office) to discuss your treatment plan. Kelley will collaborate with your primary care provider to recommend compounded BHRT prescriptions and supplements tailored to your health goals. With the $50 deposit already paid, the remaining $200 will be due at this stage.  
 

4️⃣ Progress Check (3-4 months)
Approximately 3-4 months after starting your treatment, you’ll complete a condensed symptom questionnaire and perform follow-up lab work. Kelley will review your progress and provide guidance during a 30-minute appointment to ensure your health is on track.  30-minute appointments ($100)

5️⃣ One-Year Check-In
At the 1-year mark, Kelley will revisit your symptom questionnaire and lab results during a 30-minute follow-up. This ensures your treatment remains effective and adapts to any changes in your health or symptoms. 30-minute appointments ($100)

6️⃣ Support & Minimal Maintenance
With Kelley’s thorough initial care, most patients require minimal follow-ups. However, ongoing 30-minute appointments ($100) or 15-minute “ask the clinician” sessions ($50) are available for any unique questions or treatment adjustments.

 

💡 The next step after submitting this form is to complete a comprehensive medical history and symptom assessment for Kelley to analyze.  Then, be on the lookout for an email from Kelley which will contain the details on how to order your labs.
 

👩‍💻 IMPORTANT: To ensure you receive all our communications, please add consulting@gooddaypharmacy.com to your list of trusted senders or safe contacts. 📩

 

 

Kelley, your BHRT Certified Consultant:
I am here to guide and support you through your journey with BHRT. My goal is to help you feel confident in your decisions and provide you with all the information and tools needed to achieve your best health. Please know that your well-being is my top priority, and I am always here to answer any questions or address concerns.

 

I understand that all medical treatments, including BHRT, carry risks and potential complications, as well as risks associated with not receiving treatment. These risks have been explained to me, and I confirm that all my questions have been answered. I have not been promised or guaranteed any specific results, and no warranty has been made regarding treatment outcomes.

 

I agree to:

• Proceed with treatment and follow the recommended dosages.
• Participate in ongoing monitoring, including lab tests for hormone levels or other diagnostics by a physician, primary care provider, or specialist.
• Continue regular medical care with my primary care provider, gynecologist, or other practitioners for routine exams and preventive care (e.g., physicals, mammograms, colonoscopies, pap smears, prostate exams, etc.).
  Report any adverse reactions immediately to my physician

• Communicate with my healthcare provider via email.By signing this form, I consent to receive personal health information (PHI) via email and understand that I can withdraw this consent at any time by notifying my provider in writing.
• Release Good Day Pharmacy, its healthcare providers, staff, and affiliates from liability for any adverse outcomes or complications that may arise as a result of my participation in this treatment, recognizing the unique nature of my medical background.

 

I understand that insurance may not cover evaluation, testing, or medications for this treatment, and I agree to pay for these services out-of-pocket, with no guarantee of reimbursement.

 

I confirm that this form has been explained to me, and I have been educated on the benefits, risks, and potential adverse reactions of BHRT. I have been given the opportunity to ask questions and have received satisfactory answers. I will not proceed with treatment unless I fully understand the process and risks.

 

By signing this consent, I confirm that I fully understand and accept the terms and request to begin BHRT.