Informed Consent

Hormonal Imbalance for Women

Our Pure Life Pharmacist has discussed the following topics with:
Name*
in advance of providing Patient with the medication(s) specified below and with respect to which Patient has given this Informed Consent.
  1. Patient’s current medical condition for which Patient is seeking medical treatment: Patient is experiencing generalized hormonal imbalance with an unspecified origin.
  2. Nature of the proposed medication: Bio-identical hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and anti-oxidants and/or drugs designed to alter hormone levels.
  3. Purpose of the medication: The purpose of the hormone replacement therapy is to raise levels of hormones in the patient’s body to levels in the upper normal range for younger adults in the 25-35 year age bracket. Regarding the nutritional supplements, the goal is to raise levels of vitamins, minerals and anti-oxidants in order to maximize the physiological processes in the patient’s body and minimize the damage incurred by naturally produced free radicals.
  4. Risks and hazards of the medication: Possible side effects for women on estrogen, progesterone and testosterone include breast swelling and/or discomfort, fluid retention, dizziness, break through bleeding, acne, unwanted hair growth, headache, increased risk of gallbladder disease, increased risk of blood clots, may worsen ovarian cysts, may worsen uterine fibroids, may worsen endometriosis, and may worsen fibrocystic disease. Hormone therapy may worsen breast cancer if it is present.
  5. Alternative(s) (including non-treatment) to the medication and risks associated with such alternative(s): The reasonable alternatives to this medication have been explained to the patient are as follows: 1) leave the hormone and vitamin levels as they are, 2) treating age related diseases as they appear, and 3) using pharmaceutical agents that are not bio-identical in nature. Risks associated with these alternatives are as follows: 1) There are multiple health risks that appear to be associated with the natural decline of hormones. These may include, but are not limited to increased risk of osteoporosis, risk of heart disease, dementia and certain types of cancers. 2) Many age related diseases are treated with drugs that have multiple risk factors and side effects. 3) Multiple risks have been shown to be associated with pharmaceutical, non-bio-identical, hormone alternatives.
  6. Anticipated benefits of the medication: Patients on bio-identical hormone replacement therapy frequently report increased energy, hair growth, sex drive, improved memory, mood and better sleep patterns. They also may experience an enhanced ability to maintain a healthy weight, decreased blood sugar, blood lipid levels, blood pressure and increased bone density with a decreased risk of osteoporosis.
  7. Chances of experiencing the benefits of the medication: The chance of success varies with each patient. Hormone and nutritional therapies are specifically individualized for each patient and each patient may respond differently to therapy and may experience a greater or lesser degree of success than another patient.
  8. My qualifications to prepare and dispense the medication: I am a licensed consultant pharmacist in Alabama and a Doctor of Pharmacy.

Patient: I certify that Pharmacist discussed with me all the foregoing information and that I understand the information. I had the opportunity to ask all the questions I needed to, have received all the information I require and have had sufficient time to think about the alternatives and discuss same with those people I needed to in order to make an informed decision about the treatment/procedure specified above. I understand that Pharmacist cannot:
  1. anticipate all the risks associated with the medications(s);
  2. know how I might react to such medication(s); or
  3. guarantee the anticipated benefits or chances of success of such medication(s).
I have carefully considered all the relevant information provided to me regarding the foregoing medication(s) and have determined, of my own free will, that I desire to receive the medication(s) specified above. I am of sound mind and am capable of making this decision on my own behalf.
Name*
Today's Date*
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