Female Informed Consent to Treat PATIENT INFORMATION Name * First Name Last Name Cell Phone Email * Date of Birth: MM DD YYYY I hereby give my consent to evaluation and treatment by TEMPLE WELLNESS and Kasie Barrett, FNP-BC and other healthcare practitioners of the following specified condition(s): Menopause or menopausal symptoms (including potential repletion of estrogen/estradiol, progesterone, DHEA, and/or testosterone) Other hormone imbalances - Thyroid abnormalities, Adrenal abnormalities Other – Nutritional deficiencies, IV infusion services, Peptide therapy, weight loss, etc. In addition: I acknowledge that treatment with testosterone, bio-identical 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 for anti-aging purposes unless there is true medical necessity. I agree to the administration of hormone replacement therapy and drugs designed to alter hormone levels, all as appropriate to my specific diagnosis, particular condition and treatment objectives. Alternative Treatments I have been informed about alternative treatments and understand: 1. That we can leave the hormone levels alone. 2. We can treat age-related diseases as they appear. 3. We can use pharmaceutical agents that are not bioidentical in nature (synthetics) 4. We can use a natural approach such as weight loss and nutrition instead. I understand the alternative treatments and am choosing to consent to the treatment plan prepared for me by TEMPLE WELLNESS to address the condition/conditions listed above. Side Effects and Potential Risks I understand that the possible side effects for women on estrogen, progesterone and/or testosterone may include breast swelling and/or discomfort, fluid retention, dizziness, thickening of the lining of the uterus (break-through bleeding), acne, unwanted hair growth, headaches, slight deepening of the voice, slight enlargement of the clitoris, potential increased risk of blood clots, and worsening of (1) ovarian cysts, (2) uterine fibroids, (3) endometriosis, and (4) fibrocystic disease. I understand that the possible serious side effects for women on hormone replacement therapy including estrogen, progesterone and/or testosterone can be an acceleration in the growth of gynecological cancers, 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 hormone dose and adding other medications. I acknowledge that I should take extreme precaution if I am to use topical testosterone products. If a child or other woman accidently is exposed to the testosterone cream/lotion on my body, it could cause a significant increase in their hormone levels which could result in possible side effects. Safety of Hormone Replacement Although, in my medical providers opinion, the majority of data points toward safety, there remains controversy regarding the correlation between the use of bioidentical hormone therapy and cancer. Recent data demonstrates that natural progesterone and estriol/estradiol may be protective against breast cancer. Available data supports the safety of hormone replacement therapy in women, and it is of the opinion of TEMPLE WELLNESS and Kasie Barrett, FNP-BC or other provider that treatment is safe, but there still remains controversy regarding the correlation between the use of bio-identical hormone replacement and cardiovascular events such as, but not limited to: strokes, heart attacks, and blood clots. Some studies have shown correlations between hormone replacement therapy and cardiovascular disease while others show no correlation or even a benefit in preventing cardiovascular disease. I understand that close monitoring is required by all patients to minimize and prevent any possible risks. I understand that TEMPLE WELLNESS 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 agree to obtain and remain up-to-date on all age-appropriate screenings including, but not limited to, DEXA scans, mammograms, PAP smears, pelvic 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/or OB/GYN and/or cardiologist and will not hold TEMPLE WELLNESS, Kasie Barrett, FNP-BC or any additional TEMPLE WELLNESS provider or staff responsible or liable for performing these health maintenance screenings or the treatment of any other conditions not relevant to my treatment goals. TEMPLE WELLNESS and Kasie Barrett, FNP-BC or other provider strongly recommend obtaining yearly mammograms. I understand that certain types of breast cancer, once present, can be stimulated to grow faster by estrogen that is prescribed or even the estrogen within my own body. Taking estrogen therapy with an active breast cancer could potentially decrease my chances of survival. Therefore, it is imperative to obtain appropriate yearly screenings. I agree to notify TEMPLE WELLNESS and Kasie Barrett, FNP-BC or other provider immediately if I am to become pregnant while on hormone replacement therapy and to stop it immediately. I understand that being on hormone therapy and becoming pregnant could present a risk to an unborn child. I want to initiate treatment at TEMPLE WELLNESS and I give permission to TEMPLE WELLNESS and Kasie Barrett, FNP-BC and additional providers and staff of TEMPLE WELLNESS to begin treatment with or without knowing results of age- appropriate and health maintenance screenings. In doing so, I release TEMPLE WELLNESS, Kasie Barrett, FNP-BC and other healthcare practitioners of any claims of liability for cardiovascular events, ovarian cancer, breast cancer, uterine cancer, cervical cancer and/or colon cancer. Further, I agree to immediately notify TEMPLE WELLNESS, Kasie Barrett, FNP-BC and additional staff of TEMPLE WELLNESS of any abnormal findings on any health screenings done by my primary care provider. I request from TEMPLE WELLNESS and Kasie Barrett, FNP-BC or other provider to to prescribe for me Bio-identical Hormone Replacement Therapy (BHRT). I understand that compounded BHRT is not specifically approved by the FDA for preventive medicine and my request for BHRT is off-label. I understand that the medical literature indicates that there may be health benefits to the use of BHRT and its long-term effects are undetermined. I understand that TEMPLE WELLNESS and Kasie Barrett,FNP-BC or other provider 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 any hormone replacement including BHRT has the potential to increase my risk of breast cancer and for this reason it is recommended that I have routine mammograms every 1-2 years after age 40 and prior to starting HRT. I understand that estrogen alone can cause uterine cancer and that I will need to take this with progesterone for uterine 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. I understand that this treatment requires routine lab monitoring. 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. My Obligations and Representations 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 clinic. I also promise to comply with the dosages and frequency of medications prescribed to me. I certify that I am under the regular care of a primary care provider or an OB/GYN or a Women's Health 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 condition I might have. I understand that if I do not have a primary care provider, that I will be encouraged to seek one out. I acknowledge that I am seeking care at TEMPLE WELLNESS for the specific services TEMPLE WELLNESS offers. I acknowledge I am here for specialized care including hormone restoration/optimization and/or IV vitamin infusion/injection and/or weight loss. I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with hormone restoration and treatment with TEMPLE WELLNESS. I release any claim in court or any type of complaint that could result from treatment with TEMPLE WELLNESS, Kasie Barrett, FNP-BC and any other provider or staff associated with TEMPLE WELLNESS and will not hold liable any provider or staff of TEMPLE WELLNESS. I understand that treatment modalities utilized by TEMPLE WELLNESS might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal claims. Many medical providers, including endocrinologists and OB/GYNs, might see these types of treatments as not medically necessary. Consent I hereby authorize TEMPLE WELLNESS, Kasie Barrett, FNP-BC and additional staff of TEMPLE WELLNESS to evaluate and treat conditions that I have consented for. I consent to obtaining blood work before treatment so hormone levels can be monitored, and appropriate treatment can be prescribed. I certify that I am signing this under my free will and am competent to make my own medical decisions. Indemnification Clause I, ,agree to indemnify, defend, protect and hold harmless the medical providers employed by TEMPLE WELLNESS and their respective officers, directors, collaborators, employees, stockholders, assigns, successors affiliates–indemnified parties–from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties in connection with, results from or arising out of (directly or indirectly) the medical providers employed by TEMPLE WELLNESS; rendering medical care services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by TEMPLE WELLNESS; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by TEMPLE WELLNESS. I am aware of the potential side effects and risks associated with IV infusion and injectable therapies, Infrared/NIR light therapy, peptide therapy, hormone replacement therapy, hydro massage table therapy and/or weight loss therapy provided by TEMPLE WELLNESS, accept all the risks involved and will not seek indemnification or damages from the indemnified parties. Date MM DD YYYY Signature Thank you for filling out your information!
