Consent to Treat

Hormonal Imbalance for Women

Name*

The Nature of the Treatment

I hereby give my consent to evaluation and treatment of the following specified condition(s):*

by the administration of hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and anti-oxidants and/or drugs designed to alter hormone levels, all as appropriate to my specific diagnosis, particular condition and treatment objectives.

Alternative Treatment Methods and Their General Nature

The reasonable alternatives to this treatment have been explained to me and they include:
  1. Leaving the hormone levels as they are.
  2. Treating age related diseases as they appear.
  3. Using pharmaceutical agents that are not bio-identical in nature.
I understand the foregoing alternatives and am choosing to consent to take the medications prepared for me to address the condition(s) indicated above.*

The General Nature and Extent of Treatment-Related Risks

Women: I understand that the possible side effects for women on estrogen, progesterone and/or testosterone include breast swelling and/or discomfort, fluid retention, dizziness, break through bleeding, acne, unwanted hair growth, headaches, increased risk of gallbladder disease, increased risk of blood clots, and worsening of (1) ovarian cysts, (2) uterine fibroids, (3) endometriosis, and (4) fibrocystic disease.*

Safety of Hormone Replacement

I understand that there is still some controversy regarding the correlation between the use of bio-identical hormone therapy and cancer. Recent data demonstrates that natural progesterone and estriol may be protective against breast cancer but there is no definitive information regarding the impact - positive or negative - of bio-identical hormone replacement therapy and the incidence of cancer or any other disease.

I understand that careful surveillance and close monitoring are requirements of all patients to minimize any possible risk. I understand I may request copies of all relevant studies known to my physician, and that I should discuss them with my physician.

I also understand there are possible benefits associated with this medication but that no guarantee has been made to me regarding outcomes of this treatment. I also understand that the benefits derived from antioxidant therapy will cease and those derived from hormone therapy and drugs that alter hormone levels will reverse if the therapy is discontinued.

I also understand that if I am female and become pregnant, I should stop the entire treatment protocol immediately and notify my physician. I understand that this hormone therapy is not for the purpose of preventing pregnancy, and that if I become pregnant on this therapy it could present risk to the fetus (unborn child).

My Obligations and Representations

Any questions I have regarding this medication have been answered to my satisfaction. I understand that I will be responsible for administering the hormones prescribed to me. I will comply with the recommended dose and methods of administration. I also agree to participate in any initial and subsequent hormone testing suggested by my physician and as required to monitor my hormone levels.

I certify that I am under the regular care of a physician for all medical conditions of which I am aware. I will consult my physician(s) for any other medical services I may require. I understand that Pure Life Pharmacy is a pharmacy and not a physician practice. I also understand that I will continue under the care of my physician(s) for any on-going medical condition as well as for any medical consultation that I may need.

I assume full liability for any adverse effects that may result from the non-negligent preparation of the proposed medications. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the therapy, except as that claim pertains to negligent preparation of the medications.

I fully understand the nature and purpose of portions of the aforementioned medication may be considered experimental because of the lack of adequate scientific evidence or peer-reviewed publications supporting the underlying premise of bio-identical hormone replacement therapy and that such therapy might even be considered by some medical professionals to be medically unnecessary because it is not aimed at treating a particular disease.

I understand that I may suspend or terminate the medication at any time and hereby agree to immediately notify the physician of any such suspension or termination.

Consent

I hereby authorize Pure Life Pharmacy to consult with my physician and evaluate the conditions I specified above in order to provide medication guidance to my physician. I understand my physician may be assisted by other health professionals, as necessary, and agree to their participation in my care as it relates to the evaluation and treatment of the conditions this Consent to Treat covers. I am competent to sign this Consent to Treat and have done so of my own free will.
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