AndroLift - Sublingual Testosterone/ Enclomiphene
100mg/25 mg - Testosterone/Enclomiphene ; 30 tablets - 3 month supply
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List all medications you currently take without dosages.
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List any medication or drug allergies. Write "none" if you do not have any.
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What is your last known free and/or total testosterone level? Note: you must have a value obtained from a lab report based on blood drawn in the last 6 months.
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Have you had or do you have any of the following conditions: prostate cancer or enlarged prostate, blood clotting disorders, sleep apnea, heart failure, or polycythemia (elevated hemoglobin or hematocrit?
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What symptom are you trying to resolve with the help of AndroLift? Examples include low testosterone, fatigue, low libido, brain fog, etc.
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INFORMED CONSENT FOR COMPOUNDED HORMONE THERAPYAndroLiftTM Sublingual TabletPRESCRIBING PHYSICIANDavid Mahjoubi, MDDr David Wellness, Inc.www.drdavidwellness.comPRODUCT DESCRIPTIONAndroLift is a physician-prescribed compounded sublingual tablet combining Testosterone and Enclomiphene,formulated for the support of healthy testosterone levels, strength, libido, and energy. This product is administeredsublingually (dissolved under the tongue) to facilitate absorption directly into the bloodstream. AndroLift is preparedby a licensed compounding pharmacy and is not an FDA-approved drug product. Compounded medications arecustomized preparations made to meet the specific needs of individual patients when commercially manufacturedproducts are not suitable or available.ACTIVE INGREDIENTSAndroLift contains the following active pharmaceutical ingredients. By signing this form, you acknowledge that youhave been informed of each ingredient and its general purpose:• Testosterone – A naturally occurring androgen hormone essential for the development and maintenance ofmale sexual characteristics, muscle mass, bone density, red blood cell production, libido, mood, and energylevels. Exogenous testosterone supplementation is used to restore testosterone to physiologic levels in men withclinically low testosterone (hypogonadism).• Enclomiphene – The trans-isomer of clomiphene citrate, a selective estrogen receptor modulator (SERM).Enclomiphene stimulates the body's natural production of luteinizing hormone (LH) and follicle-stimulatinghormone (FSH), which in turn supports endogenous testosterone production and spermatogenesis. It is includedto help preserve the body's natural hormonal signaling and fertility potential during testosterone therapy.INTENDED USEAndroLift is prescribed for adult male patients to support:• Restoration and maintenance of healthy testosterone levels• Improved strength, physical performance, and lean muscle mass• Enhanced libido and sexual function• Increased energy, vitality, and sense of well-being• Preservation of endogenous hormonal function and fertility potentialRISKS, SIDE EFFECTS, AND WARNINGSI understand and acknowledge the following risks and potential side effects associated with the use of AndroLift:• Cardiovascular Risks: Testosterone therapy may increase the risk of heart attack, stroke, blood clots (deepvein thrombosis, pulmonary embolism), elevated blood pressure, and other cardiovascular events. The FDA hasissued warnings regarding the cardiovascular risks associated with testosterone products. I will report any chestpain, shortness of breath, sudden weakness, leg swelling, or severe headache to my physician or emergencyservices immediately.• Polycythemia (Elevated Red Blood Cells): Testosterone may stimulate excessive red blood cell production(erythrocytosis/polycythemia), increasing blood viscosity and the risk of blood clots, stroke, or heart attack.Regular blood monitoring (CBC/hematocrit) is required.• Liver Function: Although sublingual administration reduces first-pass hepatic metabolism compared to oraltestosterone, liver function should be monitored periodically. I will report any signs of jaundice, dark urine, orabdominal pain.• Hormonal Effects: Exogenous testosterone may suppress natural testosterone production, reduce spermcount, cause testicular atrophy, and impair fertility. While enclomiphene is included to help mitigate these effects,there is no guarantee that fertility or endogenous hormone production will be fully preserved. I understand thatthis product may affect my ability to father children.• Prostate Health: Testosterone may stimulate growth of the prostate gland and could worsen benign prostatichyperplasia (BPH) symptoms. Testosterone therapy is contraindicated in men with known or suspected prostatecancer or breast cancer. I confirm I have been screened and/or have disclosed any personal or family history ofprostate or breast cancer.• Mood and Behavioral Changes: Testosterone therapy may cause mood swings, irritability, aggression,anxiety, depression, or other behavioral changes. I will notify my physician of any significant mood or personalitychanges.• Skin and Hair Effects: Potential effects include acne, oily skin, hair loss (androgenic alopecia), and increasedbody/facial hair growth.• Sleep Apnea: Testosterone may cause or worsen obstructive sleep apnea, particularly in men with risk factorssuch as obesity. I will report any symptoms of snoring, gasping during sleep, or excessive daytime sleepiness.• Estrogenic Side Effects: Testosterone may be converted to estradiol via aromatization, potentially causinggynecomastia (breast tissue enlargement), fluid retention, or bloating.• Allergic Reactions: I may experience an allergic reaction to one or more of the active or inactive ingredients,including but not limited to rash, hives, itching, swelling, difficulty breathing, or anaphylaxis. I will discontinue useand seek emergency medical attention if a severe reaction occurs.• Drug Interactions: The ingredients in AndroLift may interact with other medications I am currently taking,including but not limited to blood thinners (anticoagulants), insulin or diabetes medications, corticosteroids, andother hormonal therapies. I have disclosed all current medications to my prescribing physician.• Enclomiphene-Specific Risks: Enclomiphene may cause visual disturbances (blurred vision, visual floaters),hot flashes, headache, nausea, or gastrointestinal discomfort. If I experience any visual changes, I willdiscontinue use and contact my physician immediately.• Transference Risk: Although AndroLift is a sublingual tablet (not a topical gel), I understand that any residualmedication on my hands or mouth could potentially transfer testosterone to others, including women andchildren, which could cause serious adverse effects. I will wash my hands after handling this product and avoidclose oral contact while the tablet is dissolving.REQUIRED LABORATORY MONITORINGI understand and agree that the following laboratory tests may be required before, during, and after treatment withAndroLift, and that failure to complete recommended monitoring may result in discontinuation of my prescription:• Total and free testosterone levels• Complete blood count (CBC) including hematocrit and hemoglobin• Comprehensive metabolic panel (CMP) including liver function• Lipid panel (cholesterol and triglycerides)• Prostate-specific antigen (PSA)• Estradiol (E2) levels• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)• Additional tests as deemed necessary by my physicianNO GUARANTEE OF RESULTSI understand and acknowledge that there is no guarantee that AndroLift will increase my testosterone levels,improve strength, enhance libido, increase energy, or achieve any specific therapeutic outcome. Results varyfrom patient to patient and are influenced by many factors including age, baseline hormone levels, genetics, lifestyle,diet, exercise, sleep, stress, and overall health. This product may not be effective for my particular condition. Myphysician has made no promises or guarantees regarding the outcome of this treatment.COMPOUNDING DISCLOSUREI understand that AndroLift is a compounded medication and is not FDA-approved. Compounded medications havenot undergone the same rigorous testing for safety, efficacy, and manufacturing consistency as FDA-approvedproducts. The FDA does not verify the safety or effectiveness of compounded drugs. I accept this product with theunderstanding that it is prepared specifically for me based on a valid prescription from my physician.OFF-LABEL USE DISCLOSUREI understand that the use of testosterone and/or enclomiphene in the manner prescribed may constitute off-label use,meaning the specific combination, dosage form, and/or indication may differ from uses approved by the FDA.Off-label prescribing is a legal and commonly accepted medical practice when a physician determines it is in thepatient's best interest. I consent to this off-label use after being informed of the potential risks and benefits.CONTRAINDICATIONSI confirm that, to the best of my knowledge, none of the following apply to me. If any of these conditions exist, I willinform my physician immediately before using AndroLift:• Known or suspected prostate cancer or breast cancer• Polycythemia (hematocrit above 54%) or history of blood clotting disorders• Untreated severe obstructive sleep apnea• Uncontrolled heart failure• Current desire to conceive in the immediate near term (testosterone may impair fertility despite the inclusion ofenclomiphene)• Known hypersensitivity or allergy to testosterone, enclomiphene, clomiphene, or any excipients• Women who are pregnant, may become pregnant, or are breastfeeding (testosterone is teratogenic)• Individuals under 18 years of ageASSUMPTION OF RISK AND LIMITATION OF LIABILITYBy signing below, I voluntarily assume all risks associated with the use of AndroLift. I agree that Dr David Wellness,Inc., David Mahjoubi, MD, and their officers, employees, agents, and affiliates shall not be held liable for any adversereactions, side effects, injuries, damages, or losses arising from the use, misuse, or inability to use this product,except to the extent caused by gross negligence or willful misconduct. I understand that I use this product at my ownrisk and that my decision to proceed is made freely and voluntarily after being fully informed.PATIENT ACKNOWLEDGMENTS1. I have read and understand this entire Informed Consent form.2. I have had the opportunity to ask questions about AndroLift, its ingredients, risks, benefits, and alternatives,and my questions have been answered to my satisfaction.3. I have disclosed to my prescribing physician all known allergies, medical conditions, and current medications(including over-the-counter products, supplements, and anabolic agents).4. I understand the required laboratory monitoring and agree to complete blood work as directed by myphysician.5. I understand that I may discontinue use of this product at any time and should contact my physician if Iexperience any adverse effects. I will not abruptly discontinue without medical guidance, as hormonal withdrawaleffects may occur.6. I consent to the prescribing and use of AndroLift as described herein.7. I acknowledge that this consent form does not waive any of my legal rights.8. I agree to follow all instructions for use provided by my physician and/or pharmacist, including propersublingual administration technique.9. I understand that this medication is prescribed for my use only and I will not share, sell, or distribute it to anyother individual.10. I am aware that testosterone is classified as a Schedule III controlled substance under federal law and agreeto use it only as prescribed
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AndroLift
100mg/25 mg - Testosterone/Enclomiphene ; 30 tablets - 3 month supply
$
300.00
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I have read the privacy policy at https://drdavidwellness.com/privacy-policy/
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I confirm that I am over 18 years of age.
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I confirm that I am biologically male. Note: You may receive this product as a biologic female with a note from your primary care provider or endocrinologist.
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I understand that in case of emergency I will call 911 or go to the nearest emergency room. For non-urgent matters, I can email dr@drdavidwellness.com.
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