Dawson Integrative Medical Center, LLC: Clinical Policies and Consent for Hormone Therapy
I understand that the Hormone Therapy is to treat my primary care diagnosis to improve my primary health.
If you are late or miss your appointment, you may be subject to a $100 fee. We have a 48 hour cancellation policy.
Services must be paid for at the time of service.
Health insurance may not cover services provided at Dawson Integrative Medical Center, LLC. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company. Prior authorizations will not be completed for insurance approval.
Testosterone is considered a controlled substance. I agree that I will take my medications as prescribed. I agree to follow my medical providers instructions. I also agree that I will not sell or share my prescriptions to other individuals.
I understand that if I decide to use a compounding pharmacy that the medications are NOT FDA approved. The compounding pharmacy has rigorous inspections and regulations that are followed. Compounded medications are a great alternative for dosing, unique requirements BUT Dawson Integrative Medical Center does prefer to use retail pharmacies (Walgreens, Publix, etc) for BHRT but will work with well-known compounding pharmacies.
I understand that treatments used at Dawson Integrative Medical Center, LLC. might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and possibly weight loss treatment. Treatments may improve my primary health.
I agree that if I am having any side effects or become sick, that I will follow up with the provider or go to an urgent care or emergency department.
I acknowledge that Dawson Integrative Medical Center, LLC. is not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at Dawson Integrative Medical Center, LLC. or elect the group as my primary care.
I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.
I understand that having an appointment with Dawson Integrative Medical Center, LLC. does not necessarily entitle me to being issued a prescription for hormone replacement or additional medications. Every individual is different, and it is at the medical providers discretion to issue a prescription.
I understand that I must maintain my follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important that a medical provider manages my treatment, and it is at their discretion to provide.
I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.
I am voluntarily requesting treatment with Dawson Integrative Medical Center, LLC. regarding hormone replacement therapy, for primary care diagnosis and additional treatment modalities as determined by a mutual decision between myself and the medical provider even if my hormone levels are in normal range for my age based off of other medical society recommendations and guidelines.
Women: I do not hold any medical practitioner of Dawson Integrative Medical Center, LLC. responsible for performing breast/ovarian/cervical/uterine/prostate cancer screening, colon cancer screening, PAP smears, pelvic exams, mammograms, or other age-related preventive care. I agree that I will follow up to obtain these screenings and I hold Dawson Integrative Medical Center, LLC. harmless if an adverse event occurs during my treatment. I will ensure that my results of such screenings to Dawson Integrative Medical Center, LLC. as this could change the treatment prescribed to me.
I understand that the hormones prescribed to me are bio-identical or body-equivelant hormones like ESTRADIOL, PROGESTERONE and TESTOSTERONE. Dawson Integrative Medical Center does not typically prescribe synthetic hormones that contain estrogens or progestins (these are commonly found in birth control) as those are linked to an increase of breast cancer and blood clots. I am required to be compliant with screening mammograms and pap smears annually as any form of HRT can, in some rare cases, increase chances of cancers, blood clots, cardiovascular disease.
I understand that using progesterone alone with an intact uterus can increase my changes of endometrial or uterine cancer and that I will have to also take progesterone for protection.
I understand that while Testosterone has been shown in medical literature to have benefits in women, that it is not currently FDA approved for the use in women and that if I choose to undergo this treatment, it is an off-label treatment.
Men: Providers associated with Dawson Integrative Medical Center, LLC will evaluate and treat: Andropause or associated symptoms (including testosterone replacement, manipulating hormone levels including DHEA and estradiol); Growth hormone abnormalities including suboptimal IGF-1, decreased or suboptimal Vitamin D-3 levels; Nutritional deficiencies, overweight/obesity, B12 injections and anything else the provider deems necessary. Treatment for the aforementioned are considered off-label use of the associated medications and have not been FDA approved for the use of health optimization. I agree to the administration of BHRT or HRT designed to alter my hormone levels, which will meet my specific treatment objectives.
I understand that common side effects of testosterone replacement are acne, possible balding, enlargement of the prostate, high blood pressure, high libido, enlargement of breast tissue (we monitor and treat estrogen levels), testicular atrophy, fluid retention, infertility and an increase of the thickness of your blood (hematocrit) due to the production of red blood cells (will be monitored and treated).
I understand that the possible theoretical/possible side effects of men on testosterone replacement can be acceleration in the growth of prostate cancer, elevations in hematocrit which could potentially predispose one to a blood clot, and cardiovascular disease, including heart attacks, strokes and blood clots.
I acknowledge that I should use extreme caution if I am to use topical testosterone products. If a child or women accidently is exposed to the topical agent, it could cause a significant increase in their hormone levels which could result in possible side effects.
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I request from Dawson Integrative Medical Center, LLC., to prescribe for me Bioidentical Hormone Replacement Therapy (BHRT) to treat my primary care diagnosis.
I understand that compounded BHRT is not specifically approved by the FDA for preventive medicine.
I understand that the medical literature indicates that there may be health benefits to the use of BHRT but my long-term effects are not known.
I understand that Dawson Integrative Medical Center, LLC. cannot guarantee any results or that there will be no harm. The potential health risks and benefits of using BHRT have been explained to me to my satisfaction.
I understand that alternatives to BHRT include no treatment at all, using natural approaches or using alternatives to increase hormone levels or for symptom control.
I understand that this treatment requires routine lab monitoring. I understand that close monitoring is required by all patients to minimize and prevent any possible risks. It is important to stay up-to-date with routine screening and health maintenance by my primary care provider to prevent and detect any possible life-threatening diseases or conditions.
I understand that BHRT is purely elective and that it may not be deemed medically necessary by insurance companies.
I certify that I have read the above consent and fully understand it. I believe that I have adequate knowledge upon which to base this BHRT informed consent. I fully understand what I am signing and hereby request and consent to BHRT treatment. I have read, understand, and agree to all the above statements.