In the event we cannot contact you by the mean's you ' ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.

Bio-Identical hormone pellets are hormones, biologically identical to the hormones you make in your own body prior to menopau se. Estrogen and testosterone were made In your ovaries and adrenal gland prior to menopause. Bio-Identical hormones have the same effects on your body as your own estrogen and testosterone did when you were younger, without the monthly fluctuations (ups and downs} of menstrual cycles.

Bio-identical hormone pellets are plant derived and are FDA monitored, but not approved for female hormonal repl acement. The pellet method of hormone replacement has been used in Europe and Canada for many years and by select 08/GVNs In the United States. You will have similar risks as you hacf prior to menopause, from the effects of estrogen and androgens, given as pellets.

Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone Is category X (will cause birth defects) and cannot be given to pregnant women .

CONSENT FOR TREATMENT: I consent to the insertion of testosterone and/or estradlol pellets In my hip. I have been informed that I may experience any of the compUcations to this procedure as described below. These side effects are similar to those related to traditional testosterone and/or estrogen replacement. Surgical risks are the same as for any minor medical procedure and are included tn the ltst of overall risks below:

Bleeding, bruising, swelling, infection and pain: reaction to local anesthetic and/or preservatives; extrusion of pellets; hyper sexuality (overactive Libido}: lack of effect (from lack of absorption): breast tenderness and swelling especially In the first three weeks (estrogen pellets only); Increase in hair growth on the face, similar to pre-menopausa l patterns; water retention (estrogen only); increased growth of estrogen dependent tumors (endometrlal cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; growth of liver tumors, if already present; change In voice (which is reversible); ditoral enlargement (which Is reversible). The estradlol dosage that I may receive can aggravate fibroids or polyps, if they exist. and can cause bleeding. Testosterone therapy may Increase one's hemoglobin and hematocrit. or thicken one's blood. This problem can be diagnosed with a blood test. Thus. a complete blood count (Hemoglobin & Hematocrit) should be done at least annually. Tots condition can be reversed simply by donating blood periodically.

BENEFITS OF TESTOSTERONE PELLETS INCLUDE: Increased libido, energy, and sense of well - being ; increased muscle mass and strength and stamina; decreased frequency and severity of migraine headaches; decrease in mood swings, anxiety and irritability; decreased weight; decrease in risk or severity of diabetes; decreased risk of heart disease; decreased rfsk of Alzhei-mer's and dementia.

I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know. at this time, and that the risks and benefits of this treatment have been explained to me and I have been Informed that I may experience complications. including one or more of those listed above. I accept these risks and benefits. and I consent to the Insertion of hormone peliets under my skin. This consent is ongoing for this and all future pellet insertions.

I understand that payment is due In full at the time of service. I also understand that it is my respansibillty to submit a claim to my Insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me. dependine on my coverage. I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.

Although more insurance companies are reimbursi ng patients for the BioTE® Medical Hormone Replacement Therapy, there is no guarantee. You will be responsible for payment in full at the time of your procedure.

We will give you paperwork to send to your insurance company to file for reimbursement upon request.

New Patient Consult Fee: $150
Female Hormone Pellet Insertion Fee: $350
Male Hormone Pellet Insertion Fee: $725

We accept the following forms of payment:
Master Card, Visa, Discover, American Express, Personal Checks and Cash.

A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be bothersome.

• FLUID RETENTION: Testosterone stimulates the muscle to grow and retain water, which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot. humid weather conditions.
• SWELLING OF THE HANDS & FEET: This is common in hot and humid weather. It may be treated by drinking lots of water, re ducing your salt intake, taking cider vinegar capsules daily, (found at most health and food stores) or by taking a mild diuretic, which the office can prescribe.
• UTERINE SPOTTING/BLEEDING: This may occur in the first few months after an insertion, especially If you have been prescribed progesterone and are not taking properly: i.e. missing doses, or not taking a high enough dose. Please notify the office if this occurs. Bleeding is not necessarily an Indication of a significant uterine problem. More than likely, the uterus may be releasing tissue that needs to be eliminated. This tissue may have already been present in your uterus prior to getting pellets and is being released In response to the increase in hormones.
• MOOD SWINGS/IRRITABILITY: These may occur if you were quite deficient in hormones. They will disappear when enough hormones are in your system. SHTP can be helpful for this temporary symptom and can be purchased at many health food stores.
• FACIAL BREAKOUT: Some pimples may arise if the body is very deficient in testosterone. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.
• HAIR LOSS: Is rare and usually occurs in patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases.
• HAIR GROWTH: Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or lower abdomen. This tends to be hereditary. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem.

I acknowledge that I have received a copy and understand the instructions on this form.

• Your insertion site has been covered with two layers of bandages. Remove the outer pressure
  bandage any time after 24 hours. It must be removed as soon as it gets wet. The inner Layer is
  either waterproof foam tape or steri-strips. They should be removed in 3 days.
• We recommend putting an ice pack on the insertion area a couple of times for about 20 minutes
  each time over the next 4 to 5 hours.
• Do not take tub baths or get into a hot tub or swimming pool for 3 days. You may shower but do not scrub the site until the incision is well healed (about 7 days).
• No major exercises for the incision area for the next 3 days, this includes running, elliptical,
  squats, lunges, etc.
• The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days.
• The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief, 50 mg. orally every 6 hours. Caution this can cause drowsiness!
• You may experience bruising, swelling, and/or redness of the ins ert ion site which may last from a few days up to 2 to 3 weeks.
• You may notice some pinkish or bloody discoloration of the outer bandage. This is normal.
• If you experience bleeding from the incision, apply firm pressure for 5 minutes.
• Please call if you have any bleeding not relieved with pressure (not oozing), as this is NOT normal.
• Please call if you have any pus coming out of the insertion site, as this is NOT normal.
  
  

Reminders :

• Remember to go for your post-insertion blood work 6 weeks after the insertion.
• Most women will need re-insertions of their pellets 3-4 months after their initial insertion.
• Please call as soon as symptoms that were relieved from the pellets start to return to make an appointment for a re-insertion. The charge for the second visit will only be for the ins ert ion and not a consultation.

I acknowledge that I have received a copy and understand the Instructions on this form.

Q. What is BioTE?
A. BioTE is a Bio-Identical form of hormone therapy that seeks to return the hormone balance to youthful levels in men and women.

Q. How do I know if I'm a candidate for pellets?
A. Symptoms may vary widely from depression and anxiety to night sweats and sleeplessness for example. You will be given a lab slip to have blood work done which will determine your hormone levels. Once the doctor re-views and determines you are a candidate we will schedule an appointment for insertion.

Q. Do I have blood work dont! before each Treatment?
A. No, only initially and 4-8 weeks later to set your dosing. You may have it done again if there are significant changes.

Q. What are the pellets made from?
A. They are made from wild yarns and soy. Wild yams and soy have the highest concentration of hormones of any substance. There are no known allergens associated with wild yams and soy, because once the hormone is made It is no longer yam or soy.

Q. How long will the treatment: last?
A. Every 3-6 months depending on the person. Everyone is different so it depends on how you feel and what the doctor determines is right for you . If ycu are really active, you are under a lot of stress or it Is extremely hot your treatment may not last as long. Absorption rate is based on cardiac output.

Q. Is the therapy FDA approved?
A. What the pellets are made of is FDA approved and regulated, the process of making pellets is regulated by the State Pharmacy Board, and the distribution is regulated by the DEA and Respective State Pharmacy Boards. The PROCEDURE of placing pellets is NOT an FDA approved procedure. The pellets are derived from wild yams and soy, and are all natural and bio-identical. Meaning they are the exact replication of what the body makes.

Q. How are they administered?
A. Your practitioner will implant the pelets in the fat under the skin of the hip. A small incision is made in the hip. The pellets are inserted. No stitch is required.

Q. Does it matter if I'm on birth control?
A. No, the doctor can determine what your hormone needs are even if you are on birth control.

Q. Are there any stde effects?
A. The majority of side effects is temporary and typically only happens on the first dose. All are very treatable. There are no serious side effects.

Q. What if I'm already on HRT of some sort like creams, patches, pills?
A. This is an easy transition. The doctor will be able to determine your needs even though you may be currently taking these other forms of HRT.

Q. What if I've had breast cancer?
A. Breast cancer survivors and/or those who have a history of breast cancer in their family may still be a candidate; however, this is to be determined by tht physician. You should schedule a consultation with the Doctor.