Bioidentical Hormone Replacement Therapy (BHRT) Consent

At PriorityYou Health Center, LLC we want to ensure our patients are fully informed of the potential health risks and benefits of the treatments we provide. We encourage our patients to ask any questions regarding testosterone, estrogen, progesterone, platforms of distribution or any other inquiry you may

Bioidentical Hormones are concentrated hormones, biologically identical to the hormones you make in your own body naturally. Estrogen and testosterone are made regularly in the body but can be dramatically decreased around the time of menopause or due to other major life changes. Bioidentical Hormones have the same effects on your body that your own estrogen and testosterone did when you were younger and are believed to help restore a more revitalized, energetic and overall healthier version of yourself.

Bioidentical Hormones are made from plants and are FDA monitored but not approved for hormonal replacement. The FDA has produced the following statement: "FDA is not aware of any credible scientific evidence to support claims made regarding the safety and effectiveness of compounded BHRT drugs. No large, long term study has been done to determine the adverse effects of bio-identical hormones. The FDA does not have evidence that bioidentical hormones are safer or more effective than other hormone products."

Risks of Estrogen, Progesterone and Testosterone Hormone Replacement: (please notify medical staff if any of these side effects of treatment occur so the appropriate adjustments in the treatment regimen can be made) Lack of effect on specified symptoms, as there are no medical guarantees that symptoms will improve from treatment. PriorityYou Health Center, LLC cannot guarantee that targeted hormone levels will improve; however, symptom improvement is subjective to each patient Breast tenderness and swelling, especially in the first three weeks Increased hair growth on the face, similar to pre-menopausal patterns Water retention. Fluid entrapment.

Increase growth of estrogen dependent tumors (endometrial cancer, breast cancer Women with a past of hormone related cancers (breast, endometrial or ovarian) are preferred to be 

2 years or more in remission. There can be no guarantee that a case will not recur with or without HRT. Signing this form is a waiver stating you understand the possible risks of recurrence exists and you are willing to accept this risk to improve your quality of life Birth defects in babies exposed to testosterone during their gestation (treatment is NOT for women who are pregnant or nursing)

Growth of live tumors, if already present Change in voice, which is reversible Hyper sexuality (overactive libido) Clitoral enlargement, which is reversible Acne, skin blemishes, oily skin Uterine bleeding

Anti-depressant medications may impact symptom improvement and may take significantly longer compared to a patient who is not on anti-depressant medications Psychiatric conditions may need ongoing treatment from previously prescribed medications. Bioidentical hormone replacement may not improve symptoms associated with psychiatric

Potential Benefits of Treatments that have been explained to me include: Increased libido, energy and sense of well being Decreased frequency and severity of hormonal migraine headaches Decreased mood swings, anxiety and irritability second to hormonal decreases

Increase muscle mass and decrease subcutaneous fat

Improvement in balance Improved dry eyes Decreased central obesity Possible improvement in arthritis and fibromyalgia Improvement in quality of sleep

Patients who are not sterile and are not menopausal are advised to continue reliable birth control while participating in BHRT. Testosterone is category X, meaning it will cause birth defects and cannot be given to pregnant women. YOU MUST BE STERILIZED OR USE EFFECTIVE BIRTH CONTROL TO RECEIVE HORMONE TREATMENT. My birth control method is ___________________

PriorityYou Health Center,LLC reserves the right to discharge a patient who exhibits non-compliance with the hormone replacement therapy as prescribed, is uncooperative, does not follow medical advice, does not keep appointments, does not pay their bill or is disruptive or unpleasant to staff. We request that you give 24-hour notice when possible to reschedule or cancel your appointment.

I understand that my spouse or any other family member cannot discuss any aspect of my health or therapy participation. If I have not included their name on the HIPPA form, they will not receive a return call or reply that would verify you as a patient. This is for protection of patient privacy.

I consent to the above information related to my hormonal treatment. I have been informed that I may experience one or more of the complications listed above. My signature below certifies I have read all the above and acknowledge I have been encouraged to ask any relevant questions. I understand these treatments are FDA monitored but not approved. By beginning treatment, I accept all risks of therapy stated herein and future risk that may be reported. This consent is ongoing for present and future treatment.