I have a history of prostate cancer and voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone pellet therapy. I understand that such therapy is controversial and many doctors believe that testosterone replacement in my case is contraindicated. My clinician, Ying Liu APRN, has informed me that there is a recommendation to abstain from testosterone replacement therapies until I have been determined to be free of prostate cancer for a period of at least 2 years.
Although evidence supports the health benefits of Testosterone including the prevention of many cancers, my treating clinician has informed me that endogenous or exogenous testosterone could possibly increase the proliferation of cancerous cells in an undetected cancer. Accordingly, I am aware that prostate cancer or other cancer 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 Testosterone 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 prostate issues) that may be sustained by me in connection with my decision to undergo Testosterone 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 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 Testosterone 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.