Informed Consent for Hormone Replacement Therapy

Informed Consent for Hormone Replacement Therapy, Peptide Therapy, Anti-aging Therapy, Weight Loss Therapy, and other therapies offered at Altius Performance Medicine (Frontline Medical pLLC). It is critical to understand that the practice of medicine is not an exact nor perfect science. Treatment results can vary in their degree of efficacy and tolerance. Side effects can happen even when not predicted. Before beginning any treatment, it is essential to evaluate any potential risks as compared to possible benefits. Frontline Medical PLLC (Frontline Medical) always encourages patients to pursue independent education regarding the therapies we offer in conjunction with our provider consultations. You should also be aware of the alternatives to our treatment protocols which includes not receiving treatment. Please take the time to review the following items as part of your informed consent prior to treatment. Your provider will also attempt to answer your questions prior to initiating your treatment. This Consent Form documents that you understand the information regarding your treatment or will understand the treatment prior to initiating treatment in order to ensure you make an informed decision regarding your condition and all your options for treatment. Depending on your symptoms, medical history, and lab findings, your healthcare provider may recommend hormone/testosterone replacement therapy (HRT /TRT), peptide therapy, weight loss therapy (semaglutide), vitamin therapy, anti-aging therapies, or other medical therapies. The purpose of HRT/TRT and peptides (including testosterone, derivatives of testosterone, derivatives of pregnenolone, DHEA, estrogen, progesterone, derivatives of DHT, and peptides influencing IGF-1 levels) are intended to optimize your endogenous hormone levels in order to improve symptoms. This optimization is not intended for purposes of bodybuilding or to enhance athletic performance, but rather to alleviate symptoms, thus improving quality of life. By proceeding with treatment, you agree to abstain from using additional anabolic compounds or other performance enhancing compounds while under our medical management. Medications always have the potential to cause harmful side effects; however, there are unique side effects associated with HRT/TRT, peptides, weight loss therapies (semaglutide), vitamin therapy, and other medical therapies utilized by healthcare providers at Frontline Medical. Possible side effects are especially true when attempting to optimize hormone levels with exogenous medication. Side effects can include the following: injection site swelling and irritation, infections caused by injections, increased production of hematocrit and red blood cells, decreased sperm production, bilateral or unilateral breast swelling or tenderness (gynecomastia), increased body or facial hair, hair loss, development or worsening of sleep apnea, acne, mood changes, excessive libido, water retention and associated swelling, carpal tunnel, decreases in luteinizing hormone, decreases in follicle stimulating hormone, changes in cholesterol levels, changes in prostate specific antigen (PSA) levels, enlarged prostate (in men), enlarged clitoris (in women), voice changes, hirsutism, liver function changes, and/or kidney function changes. The following complications are rare, but may include the following: deep vein thrombosis (DVT), myocardial infarction (MI), stroke, hormone dependent cancers i.e endometrial cancer, breast cancer, or prostate cancer. Health risks increase in the setting of prior prostate cancer, breast cancer, and previous heart attack history. The long-term safety of HRT/TRT is unknown. Risks of weight loss peptide therapies (i.e. semaglutide) include studies showing a risk of thyroid C-cell tumors in rodents; human relevance has not been determined. GI (gastrointestinal) side effects are common which include nausea, vomiting, diarrhea, injection site reactions, and/or possible pancreatitis. If you have a personal history or family history of the following, you should not take semaglutide: endocrine tumors (MEN2) or family history of endocrine tumors (MEN2), eye disease, vision problems, history of pancreatitis, kidney disease, stomach problems, thyroid cancer, family history of thyroid cancer, allergic reaction to semaglutide, current pregnancy, trying to become pregnant, or breastfeeding. Many of our medications are self-administered by either subcutaneous or intramuscular injections which can lead to injection site irritation, pain, and infection. Your healthcare provider will demonstrate and educate you on proper injection techniques and injection site cleansing prior to use. It is your responsibility to voice concerns and to ask questions if not completely comfortable with this type of medication administration. By signing this form, I certify: * I have read, had this form read, and/or had this form explained to me. * I fully understand its content and agree with its contents. * I agree with and understand the risks involved with treatments provided by Frontline Medical. I understand that HRT/TRT is approved by the FDA only for deficiencies. I also understand that use of HRT/TRT, peptides, weight loss therapies (semaglutide), vitamin therapy, anti-aging therapies, and other medications prescribed by healthcare providers at Frontline Medical may be considered “off-label” use. I also understand that some therapies may not be approved by the FDA. As a patient, I assume liability for any adverse outcomes or side effects. I understand the medical literature and recommendations are rapidly changing, thus I understand the importance of periodically discussing my treatment plans with my healthcare provider at Frontline Medical. * I agree to contact a healthcare provider if the following occur: side effects as mentioned above which include: a flushed appearance, increases in blood pressure, skin changes, hair changes, sleep changes, mood changes, pain or swelling in the legs, problems urinating, and/or lumps in breasts or armpits. * I agree to seek emergency medical attention if the following symptoms develop: shortness of breath, chest pain, slurred speech, and acute onset of weakness or numbness in any part of the body. I understand there may be unforeseen risks that are not included herein and that complications or side effects may require hospitalization and outpatient therapy. * I agree to be compliant and consistent with the recommended medication dosing. I will obtain initial baseline labs and periodic labs to evaluate and ensure monitoring of treatment. I do not hold any medical provider of Frontline Medical PLLC (Frontline Medical) responsible for performing prostate cancer screening, PSA tests, and/or rectal exams. I will consult with my Primary Care Physician (PCP) and/or urologist and provide these exams and assessments when available. I will facilitate appropriate medical records and allow for physician-to-physician communication regarding my treatment when appropriate. I understand my initial and continuing treatment may depend on this information. I understand and agree that it is my responsibility to be aware of the above side effects and complications. I agree to discuss any side effects or complications with my Frontline Medical provider and/or PCP when I have a concern. * I understand and agree that no guarantees are offered regarding my expected results. I understand that my Frontline Medical provider will attempt to decrease and minimize the risks of HRT/TRT, but that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or other unpredicted side effects.