Testosterone Replacement Consent Form

Patient Basic Information Form:

to be filled out by the patient
Full Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Date
Age*
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Basic Information

to be filled out by the patient
Preferred Pharmacy*
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*
First and Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about us?*
Referral's Name (they will get $20 off their next service!)*
First and Last Name
Other*

Financial Policy

This is to inform you of your billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience we accept Visa, Mastercard, Discover, American Express, Venmo, HSA/FSA cards, and CareCredit.
I have read and understand all of the above and have agreed to these statements:*

Clear
Date*

MonthDayYear
Date
HIPAA Privacy Notice
I understand that Better Beauty & Wellness, LLC follows The HIPAA Privacy Rule which requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without your authorization. The Rule also gives you rights over your protected health information, including rights to examine and obtain a copy of your health records, request corrections, or request it be sent to another party.*

Clear
Date*

MonthDayYear
Date

Testosterone Replacement Therapy Informed Consent

To the Patient:
I hereby give my consent and hereby authorize evaluation and treatment by Better Beauty & Wellness, LLC, Kelli DiMattia, FNP, and any other provider associated with Better Beauty & Wellness, LLC for andropause or associated symptoms (including testosterone replacement, manipulating hormone levels including DHEA and estradiol), nutrition deficiencies, overweight/obesity, B12 injections and anything else the medical provider deems is necessary.

In addition, I acknowledge that treatment with testosterone, growth hormone stimulators, bioidentical hormone replacement therapy, B12, and thyroid optimization are considered off label use of the associated medications and have not been FDA approved for the use of health optimization, wellness, weight loss, and/or anti-aging purposes unless there is true medical necessity. I understand that treatment modalities utilized by Better Beauty & Wellness, LLC, might not be supported by scientific/medical literature, and could be seen as experimental or based off antidotal claims. Many medical providers, including endocrinologists, and urologists, might see these types of treatments not medically necessary. I understand that there are alternative treatments and understand we can leave my hormone levels alone, we can use a natural approach such as weight loss and nutrition instead, and we can use alternative medication to increase your testosterone levels vs. using prescription testosterone and am choosing to consent to the treatment plan prepared for me by Better Beauty & Wellness, LLC to address my concerns.

I certify that I am under the regular care of a primary care provider or a specialist for any other conditions I might have or am found to have. I will consult with my primary care provider or specialist regarding any other conditions I might have. I understand that if I do not have a primary care provider, I will be encouraged to seek one out. I acknowledge that I am seeking care at Better Beauty and Wellness, LLC for the specific services they offer. I acknowledge that I do not want to establish primary care with Better Beauty and Wellness, LLC and I am here for specialized care including testosterone replacement, hormone restoration, etc.

Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the hormones and/or medications prescribed to me if I do not have them administered to me in the clinic. I also promise to comply with the dosages and frequency of medications prescribed to me.

I agree to the administration of hormone replacement therapy, and/or nutritional supplements, and/or drugs designed to alter hormone levels which will meet my specific treatment objectives and to treat and specific diagnosis I might have. I certify that I am signing this under my free will and I'm competent to make my own medical decisions.
Signature*

Clear
Date*

MonthDayYear
Date

Safety, Side Effects, and Potential Risks

To the Patient:
Available data supports the safety of testosterone replacement therapy in men, and it is of the opinion of Better Beauty & Wellness, LLC that treatment is safe, but there remains controversy regarding the correlation between the use of testosterone replacement therapy and cardiovascular events such as but not limited to strokes, heart attacks, and blood clots. Some studies have shown correlations between testosterone replacement therapy and cardiovascular disease, while others show no correlation, or even a benefit in preventing cardiovascular disease. Nonetheless, I understand that the possible theoretical/possible side effects for men on testosterone replacement can be an 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. Most of the common side effects resolve with time. Many of these can be treated by changing your testosterone does and adding other medications.

I acknowledge that common side effects of testosterone replacement are acne, possible balding, enlargement of the prostate, high blood pressure, high libido, enlargement of breast tissue, testicular atrophy, fluid retention, infertility, and an increase in the thickness of your blood (hematocrit) due to the production of red blood cells. That said, I understand that close monitoring is required by all patients to minimize and prevent any possible risks. I understand that Better Beauty & Wellness, LLC will monitor my blood work including hormone levels. I also understand that 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 want to initiate treatment at Better Beauty & Wellness, LLC and I give permission to Better Beauty & Wellness, LLC, Kelli DiMattia, FNP, and additional staff of Better Beauty & Wellness LLC to begin treatment without knowing results of age-appropriate and health maintenance screenings. In doing so I release my ability for cardiovascular events, prostate cancer, breast cancer, testicular cancer, and/or colon cancer. Further, I agree to immediately notify Better Beauty & Wellness LLC of any abnormal findings on any health screenings done by my primary care provider. I agree to obtain and remain up to date on all age-appropriate screenings, including but not limited to digital rectal exams, colonoscopies, cardiac screenings, and any other type of recommended health screenings. I agree to obtain these screenings through the direction of my primary care provider and will not hold Better Beauty & Wellness, LLC, Kelli DiMattia, FNP or any additional staff responsible or liable for performing these health maintenance screenings or the treatment of any other conditions not relevant to my treatment goals with Better Beauty & Wellness, LLC.

I acknowledge that I should take extreme precautions if I am to use topical testosterone products. If a child or women accidently is exposed to the testosterone cream/lotion on my body if could cause a significant increase in their hormone levels which could result in possible side effects.

I have reviewed the risks mentioned and have determined the benefits outweigh the possible risks associated with hormone restoration and treatment with Better Beauty and Wellness, LLC. I release any claim in court or any type of complaint that could result from treatment with Better Beauty and Wellness, LLC, and will not hold liable any provider or staff of Better Beauty and Wellness, LLC.
Signature*

Clear
Date*

MonthDayYear
Date

Can't wait to see you!

If you have questions, you can contact me using the information below -- otherwise go on and hit submit!
Should be Empty:

	Name of Medication	Prescription or Over-the-Counter?	Dosage	Schedule
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

	Yes or No	Give more detail if desired.
Gallbladder Disorder
Liver Disease
Eating Disorder
Drug or Alcohol Abuse
Heart Valve Disorder
Heart Disease
Cancer
Kidney Disorder
Anemia
Bleeding Disorder
Thyroid Disease
HIV
Anxiety
Depression
Psychiatric Illness
other

	Yes or No	Give more detail if desired.
Problems with eating or appetite?
Do you feel unmotivated in life?
Do you have trouble sleeping?
Do you have to get up to urinate at night?
Do you have discomfort with urination?
Has the force of your urination decreased?
Kidney, bladder, or prostate infections?
Problems with emptying your bladder?
(MEN) Problems achieving or maintaining erections?
(MEN) Are your erections softer than in the past?
(MEN) Do you have ejaculation issues?
(MEN) Any testicular pain or swelling?
Recent changes in weight?
Recent changes in energy levels?
Recent changes in libido?
Family history of prostate cancer?
Family history of heart attacks or stroke?
Family history of diabetes?
Family history of high blood pressure?
Other:

Patient Basic Information Form:

Patient Basic Information

Medical History

Rate each problem from a scale of 1-10 with 1 being never and 10 being often:

Testosterone Replacement Therapy Informed Consent

Safety, Side Effects, and Potential Risks

Can't wait to see you!