Testosterone Replacement Therapy Consent Form

1
Referral Name* This field is required.
Dimitri Frangoulias
Gil Patino
Ray Rakhar, P.A.
2
Full Name* This field is required.
First Name
Last Name
3
Gender* This field is required.
Male
Female
Other
4
Date of Birth* This field is required.
5
Where Are You Located?* This field is required.
City
State
6
Phone Number* This field is required.
7
Email* This field is required.
example@example.com
8
Testosterone Replacement Therapy (TRT)

This is a treatment used to restore and maintain optimal testosterone levels in individuals with clinically low testosterone. This therapy is intended to alleviate symptoms such as fatigue, low libido, reduced muscle mass, mood changes, and cognitive decline. It may be administered via injection, transdermal, or other medically approved methods.

--------------------------------------------

Purpose of Treatment

The goal of TRT is to restore testosterone levels to the normal physiological range, relieve symptoms associated with testosterone deficiency, and improve quality of life, vitality, and metabolic health under medical supervision.
9
Kindly review the following and select any items that are applicable to your medical history or current health status.* This field is required.
I am at least 18 years old and have been evaluated for testosterone deficiency.
I do not have a history of prostate or breast cancer.
I do not have severe untreated sleep apnea, uncontrolled heart failure, or high hematocrit levels.
I understand that TRT may increase red blood cell count, which requires regular lab monitoring.
I understand the potential risks and benefits of therapy and agree to routine follow-up and lab work.
10
Please review the following conditions and check any that apply to your medical history or current health status, as they may impact treatment eligibility.
History of prostate or breast cancer
Severe untreated sleep apnea
Elevated hematocrit levels
Uncontrolled heart disease
History of blood clots or stroke
Use of anabolic steroids or TRT in the past
Current use of blood thinners
Fertility concerns or plans for future conception
None Of These
11
I understand that a licensed medical provider will review my intake form and medical history to determine if this therapy is appropriate for me. No medication will be prescribed without clinical justification and professional medical judgment.
12
Potential Risks and Side Effects

Possible risks and side effects of TRT may include acne, increased red blood cell count, fluid retention, worsening of sleep apnea, mood changes, gynecomastia, reduced fertility, and changes in cholesterol levels. In rare cases, it may contribute to prostate growth or cardiovascular concerns.

-----------------------------------------------

Monitoring and Follow-Up

I agree to participate in regular medical evaluations and lab testing to ensure the safety and effectiveness of my treatment. I will report any side effects or health changes to my provider promptly.
13
Please read and acknowledge the following disclosures to ensure informed consent and compliance with medical and legal standards.* This field is required.
I acknowledge that TRT may involve off-label prescribing based on symptoms and lab results.
I consent to receive this treatment via telehealth and agree to remote evaluation and monitoring as required.
I understand that KoreMe Anti-aging & Aesthetics Group and its providers are not liable for adverse events resulting from incomplete disclosure, noncompliance, or misuse.
I understand I may refuse or withdraw from therapy at any time without impacting future care.
14
Consent for Treatment

I have read and understand this consent form. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I voluntarily consent to begin Testosterone Replacement Therapy under the supervision of a licensed medical provider.
15
Signature* This field is required.Please sign below to confirm that the information provided is accurate and that you have read and understood the above acknowledgments.
Powered by Jotform SignClear
16
Schedule Your FREE Consultation Today!Scheduling your consultation allows us to prepare the best care plan tailored to your needs.
Should be Empty: