Testosterone Consent

Patient Consent for Hormone Replacement Therapy & Prescription Medication

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1. If my treatment includes prescription medications, I will carefully follow the instructions given, notify the doctor of any change in my medical history (especially heart or blood pressure problems) and not resell the medication nor will I share it with any friend or family member. I will not visit other doctors for the purpose of obtaining additional or duplicate medication of the same type.

2. We are not capable of serving as your primary care facility. If I become ill, I should contact my personal physician or visit an urgent care facility. If I become ill, I will arrange and obtain all age-appropriate screening through my primary care physician and will not hold the center or its physicians responsible for these screenings.

3. I will consult my primary care physician and/or endocrinologist (medical physician) to encourage and facilitate physician communication with my REGENX Health provider regarding my treatments

4. I understand that I will only receive a prescription when medically necessary and that I do not automatically qualify for therapy upon my initial assessment. Obtaining a prescription is always at the physician's discretion and is determined based on medical assessment and a diagnosis.

5. I understand that I will not receive a refund for any medications once they are dispensed from the pharmacy. Once medications leave the pharmacy, they cannot be returned.

6. I agree to administer all medications as directed by my REGENX health provider.I agree to immediately report to my REGENX Health provider verbally any adverse reactions or problems, of whatever nature, whether or not said matters relate to treatment.

7. I understand professional testosterone replacement therapy necessitates at least one in person medical evaluation by a REGENX Health provider prior to a prescription being written in addition to laboratory blood work. If I fail to submit to requested follow-ups, I understand that my REGENX Health provider, at his discretion, will discontinue my therapy until requested information is received.

8. I confirm I have reviewed the FDA labeling warning labels for intramuscular testosterone injections and transdermal testosterone preparations. If I have any concerns or questions about the FDA warning label I have been provided the opportunity to discuss my concerns with my REGENX Health provider.

FDA Warning Label for Testosterone Gel

FDA Warning Label for Testosterone Enanthate

I understand that NO PRESCRIPTION WILL BE PROVIDED UNLESS A CLINICAL NEED EXIST BASED ON REQUIRED LAB WORK, PHYSICIAN CONSULTATION, PHYSICAL EXAMINATION AND/OR CURRENT MEDICAL HISTORY. PLEASE NOTE, AGREEING TO LAB WORK AND PHYSICAL EXAM DOES NOT AUTOMATICALLY EQUATE TO CLINICAL NECESSITY AND A PRESCRIPTION

Prior to starting hormone replacement therapy for the treatment of symptomatic hypogonadism, it is important to understand the potential risks and side effects associated with therapy. It has been explained to me with my understanding that I may experience the following side effects.

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• Acne

• Breast Tenderness or Enlargement

• Moodiness or Aggressive Behavior

• Water Retention

• Hair thinning and baldness

• Hypogonadal symptoms may not improve

• Sleep Apnea/Sleep Disturbance

• Worsened Cholesterol Levels

• Worsened Liver Function tests

• Increased Red Blood Cell Levels

• Headache

• Prostate enlargement, worsening of urinary symptoms, change in PSA levels

• Decreased sperm production and infertility that may continue after stopping testosterone

• Testicular atrophy that may be permanent

• Increased risk of developing blood clots, heart attack, stroke and even death

9. I consent to have the clinic, including my REGENX Health provider, begin treatment, monitor treatment and make recommendations for testosterone replacement therapy

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10. I have been informed that the benefits of therapy are not guaranteed and if I stop the treatment my condition may return or get worse.

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11. The examination performed by the clinic does not replace the yearly exam or any other doctor’s visit by my personal physician.

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12. I agree that any new changes in medications, new surgeries or the diagnosis of new medical conditions will be brought to the attention of my REGENX Health provider.

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