Hormone Replacement Therapy (HRT) Consent

Hormone Replacement Therapy (HRT) and peptide therapy is intended to address symptoms associated with hormone imbalance or deficiency.

Presenting symptoms for treatment may include:

• Fatigue
• Thyroid imbalance
• Decreased libido
• Weight gain / metabolic dysfunction
• Mood changes
• Cognitive concerns
• Sleep concerns
• Decreased muscle mass or strength
• Menopausal or andropausal symptoms

I understand that there are potential risks that are not yet fully understood.

Therapies may include, but are not limited to and at provider's discretion:

• Testosterone (injectable, transdermal, troche)
• Estrogen (oral, transdermal, vaginal)
• Progesterone
• Dehydroepiandrosterone (DHEA)
• Human Chorionic Gonadotropin (hCG)
• Clomiphene citrate (Clomid)
• Thyroid hormone
• Sermorelin therapy
• Anastrozole (aromatase inhibitor; male patients only)
• Other adjunctive hormone-support therapies and peptides to be discussed during treatment plan

I understand that many HRT treatments may be prescribed off-label, including:

• Testosterone therapy in women and men
• Anastrozole use in men for estradiol management
• Compounded hormone formulations for women and men
• Sermorelin therapy
• Thyroid medication

I acknowledge:

• Off-label prescribing is a common and accepted medical practice
• There may be limited long-term safety data
• My provider has determined potential benefit outweighs risks but I am assuming all risk of engaging in consultation and treatment with HRT and peptide therapy

I understand that some prescribed medications may be obtained from compounding pharmacies.

I acknowledge:

• Compounded medications are not FDA-approved
• They are customized to individual prescriptions
• There may be variability in potency, sterility, and absorption
• Insurance coverage is typically not available

I agree to hold harmless the prescribing provider and affiliated entities from any adverse outcomes related to compounded medications, including variability in formulation, pharmacy preparation errors, sterility or contamination risks, adverse reactions, side effects, lack of benefit, shipping time and arrival of medication/therapy, and potential risks that are not yet fully understood.

Potential benefits of HRT may include:

• Improved energy and vitality
• Increased libido and sexual function
• Improved mood and cognition
• Increased muscle mass and strength
• Improved metabolic function

I understand that results are variable and not guaranteed.

General risks (all hormone & peptide therapies)

• Hormonal imbalance, fluid retention, mood changes, headaches
• Skin changes, lipid alterations, cancer and cellular changes
• Vision changes, sleep changes, depression/anxiety/SI or HI
• Changes in insulin sensitivity, blood sugar fluctuations, weight gain or loss
• Clot or DVT risks, CV risks, infertility
• Increased red blood cell count (polycythemia)
• Hair thinning or hair growth changes, injection site reactions
• Nausea, vomiting, diarrhea or constipation, abdominal discomfort

A. Testosterone therapy (male & female)

• Acne, oily skin; hair loss or increased body/facial hair
• Polycythemia (elevated hematocrit)
• Infertility (may be prolonged or permanent)
• Testicular atrophy (men)
• Voice deepening (women; may be irreversible)
• Clitoral enlargement (rare, women)
• Possible cardiovascular risks (data evolving)

B. Estrogen / progesterone therapy

• Breast tenderness, vaginal bleeding
• Increased risk of thromboembolic events (blood clots)
• Stroke or cardiovascular complications
• Breast cancer risk (long-term considerations)

C. hCG / clomiphene (Clomid)

• Mood changes, hormonal fluctuations, gynecomastia
• Visual disturbances (Clomid; rare but may be serious and require discontinuation)

D. Anastrozole (aromatase inhibitor — male patients)

I understand that Anastrozole may be prescribed to manage elevated estradiol levels associated with testosterone therapy.

Common / dose-related

• Joint pain or stiffness ("dry joints"), fatigue
• Decreased libido, erectile dysfunction, mood changes

Hormonal risks

• Excessive suppression of estradiol (low estrogen state)
• Negative impact on sexual function or sense of well-being

Long-term / potential risks

• Decreased bone mineral density
• Adverse lipid profile changes
• Possible cardiovascular risk with chronic over-suppression

I understand:

• Estradiol is necessary for male health
• Over-suppression may be harmful
• Dosing is individualized and requires monitoring

• Testosterone therapy may suppress sperm production
• Fertility may not fully recover after discontinuation
• Alternative therapies (hCG, Clomid) may be required to preserve fertility

I agree to:

• Complete laboratory testing as directed
• Participate in follow-up visits
• Understand therapy may be paused or discontinued if monitoring is not completed

I agree:

• To provide accurate medical history
• To disclose all medications and supplements
• To adhere strictly to prescribed dosing
• Not to share medications
• To report side effects promptly

I understand that my care may be delivered via telemedicine.

I acknowledge:

• Physical examination may be limited or absent
• Clinical decisions rely on self-reported information
• Technology failures may occur
• There are privacy risks despite safeguards
• Telemedicine may not identify all medical conditions

I voluntarily accept these limitations and risks.

I understand that many HRT and peptide treatments are:

• Elective
• Wellness-based
• Not medically required

I voluntarily elect to proceed.

• Results vary by individual
• No guarantees are made regarding outcomes

To the fullest extent permitted by law, I agree to release and hold harmless the physician, staff, affiliated entities, and contractors from any and all claims arising from participation in HRT, known and unknown risks, off-label prescribing, use of compounded medications, and hormonal side effects, including those related to testosterone, estrogen, or anastrozole.

I agree to indemnify and defend the provider and affiliated entities against any claims, damages, or liabilities arising from my use or misuse of prescribed therapies, failure to follow medical advice, or poor outcomes.

Any dispute arising from my care shall be resolved through binding arbitration, waiving the right to a jury trial, in accordance with applicable state law.

This agreement shall be governed by the laws of the state in which the provider is licensed. Venue shall be limited to that jurisdiction.

If any provision is deemed invalid, the remaining provisions shall remain in full force. Courts may modify provisions to reflect original intent.

I certify that:

• I have read and understand this document
• I have had the opportunity to ask questions
• I voluntarily consent to treatment
• I understand that there are potential risks that are not yet fully understood

When you complete your intake, your electronic acceptance serves as your signature for this consent. Patient name, date of birth, signature, and date are collected as part of your clinical intake record.