I have a history of breast cancer and I voluntarily choose to undergo implantation of subcutaneous bio-identical pellet therapy. I understand that such therapy is controversial and that many doctors believe that hormone replacement in my case is contraindicated. My clinician, Ying Liu APRN, has informed me that there is a recommendation to abstain from hormone replacement therapies until I have been determined to be free of breast cancer for a period of at least 5 years.
Although evidence supports the many health benefits of Estradiol, my treating clinician has informed me that Estradiol could possibly increase the proliferation of cancerous cells in an undetected cancer. Testosterone may also convert in the body to Estradiol, offering some small risk of exposure. Accordingly, I am aware that breast cancer or other estrogen-fed cancers could develop while on pellet therapy.
I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk. I am, therefore, choosing to undergo the Estradiol pellet therapy despite the information I was given by my treating Provider.
I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or cancer issues) that may be sustained by me in connection with my decision to undergo Estradiol 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 Anchor Medical Center and their physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of estradiol 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.