Please Note: 

This form will take approximately 10 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature.

Please do not print these forms. Please fill them out online 24 hours before our visit. We are a Paperless Practice utilzing Electronic Health Records.

All information is Confidential. 

I understand that telemedicine is the use of electronic technology for communication for the purpose of providing healthcare services wherever the doctor and the patient are located.

I understand that the institution is based in Florida and likewise uses telemedicine to conduct a consultation with their patients. 

I understand that with the use of telemedicine, the interaction shall be done through real-time audio-video communication.

I understand that the laws that protect privacy and confidentiality, as well as the confidentiality of medical information through the Health Insurance Portability and Accountability Act (HIPPA) also apply to telemedicine.

I understand that I will be responsible for any payments or coinsurances that apply to my telemedicine visit.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment; I have the right to access my information and to inspect my medical information that was transmitted through telemedicine; I have the right to privacy where it shall be necessary to seek my consent in order to disclose my information unless those that are permitted by law to disclose without the need of my consent.

I understand any lawsuit airing out of this agreement or service shall be brought to the courts of the state of Florida, to the exclusion of other states.

With the pronouncements above: 

I authorize the Institution to provide me their diagnosis, observations, recommendations regarding my condition through telemedicine.

Whenever necessary, I authorize the Institution to consult with other physicians or specialists whom they believe to have full knowledge and skills that can address my case.

I have read and understood the information provided above, my rights, and obligations regarding telemedicine. I have had the opportunity to ask questions and all of which were answered to my satisfaction. Therefore, I hereby give my consent to the use of telemedicine for medical care. 

As previously mentioned, we are a non-participaiting provider with Medicare and out-of-network providers, which we do not participate with any insurance company for provider therapy services.

 

If you belong to an HMO, Medicare or state benefit program, you must pay out-of-pocket for all therapy generated by our clinic.

 

Patient acknowledges that Top Notch Testosterone Inc. and our Medical Director, or other medical professionals have made no representation of warranty that the treatment or any portion thereof qualifies or qualify for reimbursement or assignment under Medicare, Medicaid, and/or other federal/state government or private insurance program.

 

Patient hereby covenants to Top Notch Testosterone Inc. and our Medical Director that he/she shall not submit any claim(s) to medicare or any other government program for any portion of the treatment at any time, and agrees to indemnify Top Notch Testosterone Inc. and its members and managers against any claim, action, loss, or suit and associated costs (including attorneys fees) which result, either directly or indirectly from submission by patient (or his/her authorized agent or reprewsentative) of a claim for any portion of the treatment to Medicare or federal state government program.

 

Patient acknowledges this agreement was executed before services were rendered, and that patient is not facing an urgent or emergency health situation.

 

Patient acknowledges that insurance does not cover any hormone replacement therapy and that they are personally financially respnsible for any and all shipments and/or treatments.

 

Pricing for HRT has been discuss with the patient at length. Patient is aware of recurring monthly costs, labs, and physical exam fees. 

Appointments: Please mark the date of your appointment on your calendar. While we make every effort to remind our clients of appointments by email and phone two or more days prior to the appointment, it is the client's responsibility to maintain his or her schedule. Please privide a twenty-four hour (1 full business day) appointment cancelation notice via voicemail or email. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation.

 

Monthly Program: With Top Notch Testosterone, there are no long term agreements. We provide a concierge service on a month-to-month basis. Refills must be requested by sending the request to refill@tntlowt.com or by replying YES to the refill text message you will receive when your refill is schedule to be submitted. If you are current with your payments, there will be 2 payments (1 payment every 5 weeks) for each 10 week shipment. 

Since we are a concierge service, recurring billing will continue even if refills are not requeste since we continue to keep your profile active, provide follow-ups to ensure you receive your medication in time without missing any doses while the pharmacy processes and ships out refills (typically 5-7 buiness days). We maintain the prescription for a controlled substance (testosterone) within the pharmacy. We also provide unlimited access to our staff in case you have any qestions, concerns, experiencing any unwanted symptoms, etc. As long as you are staying consistent with your medication dosing instructions, payments will line up with you refill date. (2- 5week payments collected for each 10 week supply to be shipped out. Refills will be submitted once the full 10 weeks are paid for and requested - by email or replying YES to the refill text you will receive). 

If you wish to cancel, all we require is a 30 day notice to cancel via email to info@tntlowt.com. If there is a payment due within the 30 day cancellation window, that payment will still be charged and then no further payments will be deducted. 

By agreeing to this cancellation policy, you are also stating that you understand that stopping therapy could result in your testosterone levels reducing down to where they were previously to starting therapy or lower since more time has passed and levels do reduce over time. You are also aware that if you were experiencing symptoms prior to starting therapy and those symptoms resolved while on therapy, that those symptoms could potentially come back.

 

Paid In Full Program:

Paid in full program options are for 30 weeks and 50 weeks.

30 weeks: You will receive a total of 3-10mL vials of testosterone over the 30 weeks, supplies and shipping are included in the cost.

50 weeks: You will receive a total of 5- 10mL vials of testosterone and 5- 12,000 ou vials of HCG over the 50 weeks, supplies and shipping are included in the cost.

ALL SALES FINAL FOR PAID IN FULL PROGRAMS. 

Informed Consent for:

Testosterone Replacement Therapy

Although Testosterone Replacement Therapy (“TRT”) has been utilized safely and effectively, it is necessary to discuss potential risks.
You should also be aware of the alternatives to TRT, including not receiving the treatment. It is important that you consider the
information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take
some time to weigh your options or consult another health care provider.
Please review the following items, which discuss informed consent. Your clinical provider will attempt to answer all of your
questions to your satisfaction. Initial beside each statement that you have read, understand, and agree with:
___ 1. This is my consent for Jude Acloque, M.D., (“Top Notch Testosterone Inc.”), including any clinical provider who works with Top Notch Testosterone Inc., to begin treatment for TRT injection form.
___ 2. It has been explained to me, the Food and Drug Administration (FDA) has removed the black box warning on testosterone products.
In February 2025, the FDA announced that it was updating the labeling for testosterone products based on new evidence from the Testosterone Replacement Therapy for Assessment of Long-Term Vascular Events and Efficacy Response (TRAVERSE) trial. The trial found that testosterone therapy did not increase the risk of major cardiovascular events, such as heart attack and stroke.
As a result, the FDA removed the black box warning, which previously stated that testosterone therapy could increase the risk of heart attack, stroke, and other cardiovascular events.

___ 3. It has been explained to me, and I fully understand, that occasionally there are complications with this treatment such as
increased body hair, acne, and male-pattern baldness (if you have the gene).
___ 4. I understand I may retain extra fluid in the body – This can potentially cause an increase in blood pressure.
___ 5. TRT may cause your LH and FSH levels to be severely limited, affecting your fertility. It is highly recommended that patients should complete a fertility test to determine current fertility status and/or speak with a fertility doctor prior to starting treatment. Infirtility is NOT guaranteed while on TRT and should not be used as a form of birth control.
___ 6. I have been informed that Testosterone may lead to liver inflammation or damage. I have been informed that I will be monitored for liver problems before starting TRT and periodically during therapy via blood tests.
___ 7. TRT may cause changes in cholesterol levels, red blood cell levels, liver function enzymes, and other hormone levels which will be monitored with periodic blood tests.
___8. I understand it is my responsibility to be aware of the above complications and let my clinical provider know when I have a
concern.
___ 9. I understand that I will have periodic blood tests to monitor my blood levels and not complying with such tests wil result in the termination of your treatment.
___ 10. I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse.
___11. I have provided my clinical provider with my complete past medical and health history. I have had an opportunity to discuss
with my clinical provider my complete past medical and health history. All of my questions concerning the risks, benefits, and
alternatives have been answered. I am satisfied with the answers.
___12. I agree that TRT works best when I change lifestyle habits such as limiting alcohol, stopping smoking, exercising, and eating correctly.

All of my questions and concerns regarding treatment have been answered to my satisfaction. I further acknowledge that the risks
and benefits of this treatment have been explained to me. I am of sound mind, under no undue influence and am competent to
make this decision and do so of my own free will. I have no further questions.

I consent to taking Testosterone as proposed by my clinical provider. I have complete understanding of and agree to follow the
terms of this Informed Consent. 

Informed Consent for:

GLP-1

 

INFORMED CONSENT FOR COMPOUNDED GLUCAGON-LIKE PEPTIDE-1 AGONIST (GLP-1) MEDICATIONS
 

This document is intended to serve as confirmation of informed consent to receive a prescription for a compounded medications, including Glucagon-like Peptide-1 Agonist (GLP-1) Injections (Semaglutide,Tirzepatide or Liraglutide), which are prescription medications used for weight loss.

You acknowledge that you understand and agree with the following:

I do not have any of the following conditions:

A personal or family history of Medullary Thyroid Carcinoma (thyroid cancer)
Multiple Endocrine Neoplasia Syndrome Type 2
A serious allergic reaction to semaglutide or any of the ingredients in Olympia Pharmaceutical compounded semaglutide.
Am pregnant, plan to become pregnant in the next two months, or am breastfeeding
A serious allergic reaction to another GLP-1 medication (a medication similar to what you are being prescribed).
 

I understand that the following possible side effects may occur. This is not an all-inclusive list. For more information on this medication, you may consult with your prescriber, pharmacist, or other healthcare practitioner,

 

Most Common Side Effects: Nausea, Vomiting, Diarrhea, Constipation, Abdominal Pain, Headache, Fatigue, Dyspepsia, Dizziness, Abdominal Distention, Belching, Hypoglycemia, Flatulence, Gastroenteritis, Gastroesophageal Reflux Disease, Injection Site Reactions (itching or burning at site of administration with/without thickening of the skin).

 

Less Common but Serious Side Effects: Pancreatitis (inflammation of the pancreas), hypoglycemia (low blood sugar), acute gallbladder disease including gallstones, acute kidney problems (kidney failure), serious allergic Reactions (including swelling of your face, lips, tongue, or throat, severe rash or itching, very rapid heartbeat, problems breathing or swallowing, or fainting or feeling dizzy), change in vision in people with type 2 diabetes, increase in heart rate (heart racing that lasts for several minutes), depression, or thoughts of suicide.

 

BLACK BOX WARNING: RISK OF THYROID C-CELL TUMORS

This medication has been found to cause a specific type of thyroid tumor (thyroid C-cell tumors) in rats and mice. It’s not known if this medication can cause similar tumors in humans. Discuss the benefits and risks of this treatment with your clinician. This medication should NOT be used by people with a personal or family history of medullary thyroid carcinoma (MTC) or those with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While using this medication, contact your clinician immediately if you notice any signs of thyroid tumors, such as an unusual growth or lump in the neck, difficulty swallowing, shortness of breath, or persistent hoarseness.

 

I understand that certain drug interactions may occur.

I will not use this medication with any other product that contains semaglutide or other medications that are similar to this medication (such as tirzepatide, liraglutide, exenatide, dulaglutide, Wegovy, Ozempic, Rybelsus, Mounjaro, Zepbound, Saxenda, Victoza, or Trulicity).
I understand that when I take compounded semaglutide with other medications by mouth, it might slow down how quickly my stomach empties, which could affect how well my body absorbs other medications. I will update my clinician on a complete list of my medications
The risk of my blood sugar dropping may be higher if I use compounded semaglutide with another medicine that can cause low blood sugar, such as sulfonylureas, insulin, Dipeptidyl peptidase-4 inhibitors (DPP-4s), and meglitinides.
I will keep my health care providers, including my WeightWatchers Clinic clinician, updated on all the medications I am taking, including dietary supplements.
 

I will follow any directions for use provided to me by my pharmacist or my healthcare provider, including the following:

I understand this medication must be self-injected in the subcutaneous tissues (under the skin) once weekly.
I understand this medication must be kept refrigerated and expires after 28 days of the initial puncture of the medication vial.
I will notify my provider If I experience side effects or if I am having trouble with administration.
I will not share this medication (or needles) with others and agree to dispose of needles and excess medication safely and within 28 days of the initial puncture of medication vial.
I will not adjust any dosage without the express instructions of my Clinician.
 

I have told my clinician about all of my medical conditions, including:

Any personal or family history of medullary thyroid carcinoma (MTC) or with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Problems with my pancreas or kidneys
Severe problems with my stomach, including gastroparesis or problems digesting food
Any history of diabetic retinopathy
Am pregnant or plan to become pregnant
Type 1 or type 2 diabetes
History of Pancreatitis
Gallbladder issues
History of Eating Disorders
Depression
Suicidal thoughts or behavior
History of a suicide attempt
All Medications and supplements I am currently taking
Known drug allergies
 

I give consent for the GLP-1 agonist prescription and the anticipated dosage range. By checking the box next to “Compounded GLP-1 Informed Consent,” i also indicate that I understand the following:

 

This medication consent is effective immediately. The need for and continued prescriptions for this medication will be reviewed at the clinician’s discretion. I can refuse to give consent or can withdraw my consent at any time with written notification to my assigned clinician. This will not affect my right to change my decision at a later date. If I refuse to give consent or withdraw consent I will not be eligible to receive a prescription for a GLP-1 agonist prescription.

 

I understand this prescription comes from a compounding pharmacy and is not FDA approved. I understand this medication could be harmful if taken inappropriately and should be used only as prescribed. I acknowledge that no guarantees have been made to me concerning my results. My consent permits the dose to be changed within the anticipated dosage range without signing another consent.

I certify that I have read the contents of this form in its entirety. I have had the opportunity to ask questions and have had my questions answered. I understand the benefits and risks of the medication. I understand that my receipt of this medication is subject to reporting, by my pharmacy, to the prescribing physician, and/or the manufacturer, if required, and I authorize these disclosures. I am 18 years of age or older and authorized to execute this consent form. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

Privacy of your personal information is an important part of Top Notch Testosterone Inc, Telemedicine practice, while providing you with quality hormone replacement therapy. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. 

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. All electronic forms and consent forms are viewed only by Top Notch Testosterone Inc. unless you have specifically signed a Release of Records to make these forms available to another Health Care Provider or family member.

 

Our Privacy Policy at Top Notch Testosterone Inc. outlines what we are doing to ensure that:

• Only necessary information is collected about you;
• We only share your information with your consent;
• Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols.

 

How our Clinic Collects, Uses and Discloses Patients’ Personal Information:

The Clinic, Top Notch Testosterone Inc. understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information. 

The clinic will collect, use and disclose information about you for the following purposes: 

• To assess your health concerns
• To provide health care 
• To advise you of treatment options 
• To establish and maintain contact with you 
• To send you newsletters and other information mailings 
• To remind you of upcoming appointments 
• To communicate with other treating health-care providers 
• To allow us to efficiently follow-up for treatment, care and billing 
• To complete claims for insurance purposes 
• To invoice for goods and services 
• To process credit card payments 
• To collect unpaid accounts 
• To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others
• To use for educational and research purposes (this includes case summaries, photographs, lab results and other pertinent medical information). Your identity will be protected at all times and if necessary, identifying information will be altered to protect your privacy in all the above instances 

 

By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.

Patient Consent:

 

I have reviewed the above information that explains how Top Notch Testosterone Inc. will use my personal information and the steps that the clinic is taking to protect my information. 

I agree that Top Notch Testosterone Inc. can collect, use and disclose personal information as set out above in the information about the clinic's privacy policies. 

EMAIL CONSENT

 

In order to contact patients about appointment reminders, follow-ups blood work, symptom check-ins, clinic changes, promotions, products, events, newsletters, and programs, we require your consent below. You may choose to withdraw consent at any time and you will no longer receive emails or text messages from our encrypted, HIPAA Compliant software from Top Notch Testosterone Inc.

 

Top Notch Testosterone Inc.

11555 Heron Bay Blvd Ste: 200

Coral Springs, FL 33076

954-519-5750

info@tntlowt.com

 

 

COMMUNICATION POLICY

 

I want to provide you with support on your journey towards hormone optimization, and I endorse transparency and setting expectations up front so we are both on the same page with what I can provide outside of our visits together. This is our Communication Policy:

- Questions are not answered on text message (outside of our patient portal) or Social Media Platforms for legal reasons and HIPAA compliance.

- Email poses security risks. To ask questions online, please utilize the Secure Messaging System through your Patient Portal. Questions will be answered by my next business day.

- Complex questions and new concerns: please book a 15 or 30 minute follow-up visit so we can provide you with the hormone therapy support you deserve.

Note: We use an Electronic Health Records software for all Patient Charts which is HIPAA-Compliant and provides industry-leading data system security. It allows you to instantly access your records online and communicate with your doctor securely.

PLEASE ENSURE the email address you enter is Accurate as this is the number one reason people are unable to access their online charts!

PLEASE CLICK "CONTINUE" BELOW TO COMPLETE AND SUBMIT YOUR FORM.

 

Thank you for choosing Top Notch Testosterone Inc. for your hormone optimization and/or medical weight loss solution.

 

Email: Info@tntlowt.com or contact your sales rep if you have any further questions.