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Hormone Optimization Consent Form

Consent Form - Hormone Treatment For Men

Patient Name:
Address:
Date of Birth:
Phone Number:
Email Address:

I hereby give my consent for evaluation and treatment of androgen deficiency, and other hormone imbalances by the administration of hormone replacement and/or hormone stimulation therapy. I also offer consent to use nutritional supplements including vitamins, minerals, herbs and plant extracts, glandular extracts, and drugs designed to alter hormone levels. The nature of the procedure is to raise levels of testosterone in my body to an upper normal range consistent with youthful age limits.

Alternative Treatment Methods

The reasonable alternatives to this treatment have been explained to me and they include: 1. Leave 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.

Treatment Related Risks

Possible side effects for men on testosterone replacement are acne, persistent erections, unwanted hair growth, enlargement of the prostate, enlargement of breast tissue, testicular atrophy (shrinkage), and reduced sperm counts to near "sterile" levels. Treatment of testosterone deficiency is safe and effective but ti must be acknowledged that there is some potential for side effects. The following si a general account of what has been reported in the literature as possible effects from replacement therapy. The following does not reflect the results witnessed by clinicians here at Icon Anti-aging & Aesthetics, as well feel that most standard therapies use excessive testosterone dosing in a protocol more likely to result in side effects:

Acne: 0-4%
Alopecia (hair loss): 0-1%
Anxiety: <1%
Breast Pain: 0-2%
Depression: 0-1%
Dizziness: <1%
Dry skin: <1%
Emotional Lability: 0-3%
Gynecomastia (male breast development) 0-2%
Headache: 0-3% Hirsutism (body hair): <1%
Hostility: <1%
Hypertension: 0-3%
Insomnia: 0-1%
- Lab abnormality: 0-5%
- Elevated hemoglobin and hematocrit, elevated triglycerides, hyperlipidemia, reduced HDL, elevated glucose, elevated creatinine, elevated bilirubin and transaminases. Elevation in PSA is expected, but average increase is approximately 0.1 - 0.3 ng/ml. PSA will be closely monitored during your treatment.
Libido decreased: 0-2% Nausea: 0-1%
Paresthesia (skin tingling or numbness): <1%
Priapism (prolonged erections): 0-1%
Prostate disorder: 0-5%
- An elevation in PSA or benign prostatic hypertrophy (BPH).
  Testosterone replacement should not be given to patients with active prostate cancer.
Rash: 0-4%
- Skin irritation from application of cream or patch
Sweating: <1%
Testicular disorder: 0-1%
- Varicocele (a benign occurrence), or testicular sensitivity.
Urination (impaired): <1%
- Urinary hesitancy, urgency, incontinence and retention.
Vasodilation (hot flush): 0-1%
Weight gain: 0-1%

A rectal exam to evaluate the prostate is important in the course of treatment. This may be performed by my primary care doctor, urologist or by Dr. Zayid. This in conjunction with your present PSA level is used to evaluate the likelihood of active prostate cancer. If there is concern that active prostate cancer may exist then testosterone therapy will not be initiated. It is impossible, however, to know with certainty, and it is conceivable, that a small foci of active prostate cancer is present at the time of initial treatment. This si why close follow up si critical. Testosterone given to an active prostate cancer could accelerate the disease. This occurrence should be heralded by a rise in PSA and a reduction in Free PSA % which makes lab follow-up essential.

DRUG INTERACTIONS

Insulin: Changes in insulin sensitivity or glycemic control may occur in patients treated with androgens. In diabetic patients, the metabolic effects of androgens may decrease blood glucose and, therefore, decrease insulin requirements. This is the desired effect as testosterone works to enable insulin receptors to work more efficiently. Diabetic medication may require adjustment as a result of and rogen treatment.

Corticosteroids: The concurrent use of testosterone with ACTH or corticosteroids may result in increased
fluid retention and should be monitored cautiously, particularly in patients with cardiac, renal or hepatic disease.

Oral Anticoagulants: Changes in anticoagulant activity may be seen with androgens. More frequent monitoring of I N and prothrombin time are recommended in patients taking anticoagulants, especially at the initiation and termination of androgen therapy.

Safety of Hormone Replacement
The majority of scientific data points toward the safety of using bio-identical hormones, but no one can prove or disprove a causal relationship between the use of bio-identical hormone therapy and cancer. I understand that careful surveillance and close monitoring are required of al patients to minimize any possible risk. I realize that it may be 20 years before we know if there is any true cause and effect between bio-identical hormones and increased risk for prostate cancer.

I also understand there are possible benefits associated with hormone replacement and these have been discussed in the office with Dr Zayid. I understand that no guarantee has been made to me regarding outcomes of this treatment. I also understand that the benefits derived from hormone therapy will cease and reverse if the therapy is discontinued.

I also understand that I may be prescribed "off-label" use of FDA approved drugs such as Anastrazole and Finasteride and others that may be recommended later. Off-label use means that the drug is FDA approved but being used for a purpose other than those which the FDA approved them for. Off-label prescribing is a legal and common practice by physicians in the United States.

I understand that I will be responsible for administering the hormones prescribed to me. I will conform and comply with the recommended dose and method of administration. I also agree to conform to the request for initial and subsequent blood tests as required to monitor my hormone levels.

I authorize my physician (Dr. Zayid) to perform this treatment. I understand that he will be assisted by other health care professionals as necessary and agree to their participation in my care. I certify that I am under the regular care of my primary care physician for all other medical conditions.

I will consult my primary care physician for any other medical services I may require and continue my care with my primary physician. I understand that this is a specialized practice at the Icon Anti-aging & Aesthetics that will at times overlap with treatments from my primary care physician but Dr. Zayid will always work in my best interest.

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

I hereby confirm that the nature and purpose of portions of the aforementioned treatment are considered by some to be medically unnecessary and/or experimental because they are not aimed at treating a disease, and there are no long-term studies documenting the results. The risks involved and the possibilities of complications have been explained to me.

I fully understand that the treatment to be provided may be considered experimental and unproven by scientific testing and peer-reviewed publications.I further consent to the utilization of the results of my progress in any research study performed by my physician. I understand that my name will not be used and that every effort will be made to protect my
privacy.

I understand that I may suspend or terminate treatment at any time and hereby agree to immediately notify Dr. Zayid of any such suspension or termination.

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March 6, 2023 9:43 am EST

Hormone Optimization Consent Form Uploaded by Dr. Alex Zayid - [email protected] IP 98.250.179.119