Women Sign Up – Tennessee

1. I agree to comply with all requirements for blood work and provider consultation. I understand that if i cannot receive any additional medications and treatment if i refuse blood work when required.
2. I understand that if i am more than 10min late for my scheduled appointment, i will have to be rescheduled for the next available appointment.
3. No walk ins
4. I understand that if i decide to discontinue services with the clinic,it will be my responsibility to notify the staff and cancel my payments. No refunds will be issued for automatic payment that had already come out. All cancellations must happen before the next scheduled payments, not the day of or after.
   
5. No appointments will be scheduled 30 min before closing time and no patients will be seen at that time if they walk in.
6. We accept credit or debit only no cash and no checks under any circumsatnces
7. Mininmum of 24hrs notice is required for any medication pick up

Since 1996 certain laws have been enforced regarding medical record privacy (Health Insurance Portability and Accountability Act) or HIPAA. Under the law, we are now required to notify you of this, so here is a short version of these regulations for your convenience. The full seven page privacy notice is available here for you to read and you can ask for your own copy.

This Notice of Privacy Practices describes the ways we are allowed by law to use your protected health information (medical records) or PHI to carry out treatment, payment, and other health care operations and for other purposes that are permitted or required by law. It also describes our rights to access and control your PHI. We are required to abide by these privacy rules.

According to privacy laws, your physician will use your PHI as he or she has always done for treatment, payment, or other health care operations. In addition we may also disclose your PHI from time to time to other physicians or health care providers who become involved in taking care of you. Your PHI will be used, as needed in order for us to obtain payment for our services. Front desk sign in sheets will be used where you will be asked to sign your name and we will call you by name in the waiting room when the doctor is ready to see you. We may also use your PHI when necessary to contact you concerning your appointment. We will share your PHI with business associates who perform services for us. This could include billing services or transcribing services. They are also required to maintain confidentiality.

Your PHI could be used to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you. Other uses or disclosures will be made only with your written authorization, unless otherwise allowed or required by law. You may revoke this authorization at any time in writing.

Unless you object, we may reveal (with your signed consent ) to a member of your family, close friend, or other person you choose, parts of your PHI that related to that person’s involvement in your health care. If you are unable to agree or object to this , as in an emergency, your physician will try to obtain your consent as soon as possible. Your PHI may be disclosed to public health agencies or law enforcement as needed to protect you or others. Your PHI may be disclosed by us in order to comply with workman’s compensation laws. If you are an inmate, we may disclose necessary information to the staff of the institution.

You have the right to inspect and copy your PHI except for certain legal limitations. You may ask us not to disclose your PHI for purposes of treatment, payment, or health care operations, as well as family members. This must be specific in writing. However, your doctor is not required to agree to such restrictions if he or she believes it is not in your best interest. You may ask your PHI to be amended. You also have the right to know to whom we have revealed your information if it is other than your treatment, payment, or health care operations.

I, the undersigned, authorize and give my Informed Consent to Dr. Louis Huesmann, MD, for the administration of hormone replacement therapy.

Expected Benefits of Hormone Replacement Therapy

• Expected benefits include control of symptoms associated with declining hormone levels.
• Possible benefits of this therapy may help prevent, reduce or control physical diseases and dysfunction associated with declining hormone levels, through hormonal replacement.
• I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medical community as new, controversial, and unnecessary by the Food and Drug Administration.
• I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of hormone replacement therapy.

Risks and Side Effects of Hormone Replacement Therapy

Some of the following risks/adverse reactions are derived from the official Food and Drug Administration “FDA” labeling requirements for these drugs, for therapeutic drug levels in the blood stream. My healthcare provider may prescribe these medications at dosages designed to achieve physiologic levels of hormones in my blood stream or urine generally associated with those of a 20-35 year-old person and would be within the “normal” or “average” blood concentrations of that age group.

General

• I understand that the general risks of this proposed therapy may include, but are not limited to, bruising, soreness or pain, and possible infection for hormones administered by injection.
• I understand that there are risks (both known and unknown) to any medical procedure, treatment and therapy, and that it is not possible to guarantee or give assurance of a successful result. I acknowledge and accept these known and unknown general risks.

Testosterone

A prescription hormone, given by injection, transdermal cream or patch.

• Risks of testosterone replacement include, but are not limited to: stimulation of benign and malignant prostate tumor. Testosterone replacement is contraindicated in patients with known prostate cancer.
• Side effects of testosterone replacement may include, but are not limited to: an increase in the red blood cells, determined by periodic measuring of your red blood. It is not a common occurrence and generally poses no health risk; it can be corrected by donating blood or with a therapeutic phlebotomy. Male pattern baldness, gynecomastia (breast enlargement), diminished sperm production and a reduction in the size of the testicles may develop in men. Testosterone replacement may reduce insulin requirements in insulin-dependent diabetics. Older male patients may be at a slightly increased risk for the development of prostate enlargement when replacing testosterone. The concurrent use of testosterone with corticosteroids may enhance edema (fluid retention) formation. Edema may be a complication with testosterone replacement in patients with pre-existing cardiac, renal, or hepatic disease. It is not known whether testosterone replacement therapy will increase the risk for prostate cancer.
• The most common immediate side effects (occurring in approximately no more than 6% of users) include, but are not limited to: acne, application site reaction, headache, hypertension (high blood pressure), abnormal liver function tests, and non-cancerous prostate disorder. Other side effects may include greasy hair and skin, a strong body odor, and aggressiveness.

Estrogen

• A prescription hormone, given by injection, orally or by transdermal cream or patch.
• Risks associated with estrogen replacement include, but are not limited to: heart attacks, blood clot formation, gallstones, increased risk of uterine cancer (if progesterone is not administered with concurrently) and fibroid tumors. The Women’s Health Initiative study demonstrated increased risk when estrogen replacement is initiated 10 or more years after menopause.
• Estrogen replacement is not recommended in women with a history of the following conditions: breast or uterine cancer, phlebitis and blood clots, gall bladder disease, uterine fibroma, and liver disease.
• Side effects may include, but are not limited to: increased body fat, fluid retention, uterine bleeding, depression, headaches, impaired glucose tolerance, and aggravation of migraines.

Progesterone

• A prescription hormone, given orally or by transdermal cream.
• Risks of progesterone replacement include, but are not limited to: Progestins are not the same as natural progesterone. Progestins may cancel the protective effect of estradiol, and promote constriction of the coronary arteries to a significant degree. Natural progesterone, on the other hand, may protect the endometrium, preserve the beneficial effects of estrogen on the cardiovascular system and exert no negative effects on the blood vessels that supply your heart. Progestins may cause birth defects, damage to nerve cells, blood clots, and breast cancer.
• Side effects of progesterone replacement may include, but are not limited to: nipple or breast tenderness, drowsiness, fluid retention, slight dizziness, anxiety, difficulty sleeping, depression, acne, rashes, hot flashes, appetite increases and weight gain.

Thyroid Hormone

• A prescription hormone taken by mouth.
• Risks/adverse reactions include, but are not limited to: palpitations and rapid heart rate, heart arrhythmias, excitability, increased metabolism. Cardiac sensitivity is a contraindication to thyroid replacement therapy. Excess amounts may increase the risk for osteoporosis in some people and suppress the body’s own ability to manufacture its own thyroid hormone.
• Side effects may include, but are not limited to: sleep disturbances, fine trembling of fingers, excessive hunger and thirst, sweating, anxiety, and headaches.

Dehydroepiandrosterone - DHEA

• DHEA is classified as a dietary supplement, given by mouth or by transdermal cream.
• Risks of DHEA replacement include, but are not limited to: worsening of certain cancers and should be avoided in men with existing prostate cancer and in women with breast cancer. DHEA replacement is not generally recommended in adults under age 35.
• Side effects of DHEA replacement are generally dose related and may include, but are not limited to: acne or oily skin, hair growth on the face, arms or legs, acne in women, and prostate enlargement in men male pattern baldness, decreased HDL cholesterol, fatigue, mood changes, weight gain, and insomnia.

Melatonin

• A non-prescription hormone given by mouth.
• Risks of Melatonin replacement include, but are not limited to: nighttime exacerbation of asthma. It should be used cautiously when treating some autoimmune diseases and leukemia, Hodgkin’s disease or lymphoma.
• Side effects of Melatonin replacement may include, but are not limited to: sleep disorders, bizarre dreams, headache, fatigue, stomach discomfort, and suppression of male sex drive.

Pregnenolone

• A non-prescription hormone given by mouth.
• Risks with pregnenolone replacement include, but are not limited to: exacerbation of various cancers and should be avoided in those with cancer of the prostate, breast or uterus. Very high doses may cause cardiac arrhythmias.
• Side effects of Pregnenolone replacement may include, but are not limited to: headaches, bloating, menstrual irregularities, heartburn, acne, agitation, sedation, rash and flushing.

Alternatives to Hormone Replacement Therapy

• I understand the reasonable alternatives to hormone replacement therapy, which include:
• Leaving the hormone levels as they are and doing nothing. Risks may include, but are not limited to: experiencing symptoms of hormone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining hormone levels. This alternative may result in the need to treat diseases or dysfunction associated with declining hormone levels as they appear clinically.
• Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies. Risks may include, but are not limited to: increased risk for aging-related diseases resulting from declining hormone levels

My Compliance Obligation While Receiving Hormone Replacement Therapy

• I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting, taking by mouth, applying to my skin, or administrating the hormone(s) that may be prescribed to me, and consent to periodic monitoring, when requested, which may include
• Laboratory monitoring of blood or urine chemistries and hormone levels
• Physical examinations
• Regular screening evaluations
• I agree to notify you regarding all signs or symptoms of possible reactions to my therapy.
• I agree to comply with all other healthy lifestyle activities that have been individually recommended for me. I have completely disclosed my medical history, including prescription and non-prescription medications that I am currently taking or plan to take during my treatment, as well as any other over-the-counter medications, recreational drugs or social substances, herbs, extracts, and other dietary supplements to you. I agree to comply with the recommendations regarding the continuation or discontinuation of these preparations.
• In the future I will receive recommendations in advance from you before stopping any prescribed therapeutic regimens or taking additional preparations that are not recommended by you.
• I certify that I am under the care of a physician(s) for any and all other medical conditions.

Research and Economic Interests

• I understand that the prescribing practitioner is not engaged in any personal research and has no economic interests unrelated to my immediate care or treatment that may affect the physician’s choice of treatment or medical judgment
• I certify that I have been given the opportunity to ask any and all questions I have concerning the proposed treatment, and I received all requested information and all questions were answered. I fully understand that I have the right to not consent to hormone replacement therapy. I believe I have adequate knowledge upon which to base an informed consent.
• I do now attest to reading and fully understanding this form and the contents and clinical meanings of such, and discussing these procedures with my healthcare provider and consent to this treatment, and hereby affix my signature to this authorization for this proposed long-term treatment. I have been given a copy of this consent form, and I understand fully any and all of the possibly represented implications and meanings of its writing and expectations.

Notice: This is not required. You can skip if you do not want to consent for photography (before/after shots).

I consent for medical photographs to be made of me or my child (or for person whom I am legal guardian). I understand that the information may be used in my medical record, for purposes of medical teaching at Low T Medical Clinic LLC, or for publication in medical textbooks or journals as I have designated below. By consenting to these medical photographs I understand that I will not receive payment from any party. Refusal to consent to photographs will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future I may contact the staff at Low T Medical Clinic LLC.

By agreeing to this form, I confirm that this consent form has been explained to me in terms which I understand.

I understand, as set forth in the above named practice’s Notice of Privacy Practices, I have the right to revoke this authorization, in writing, at any time by sending written notification to the Privacy Officer, except to the extent that the person or organization that is to make the disclosure has already taken action in reliance on my authorization.

II understand that I have the right to refuse to sign this authorization or to inspect (or copy) my protected health information to be used or disclosed as permitted under federal and state laws.

I understand the Practice will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure. Further, if the practice will receive payment for obtaining this information, I understand I will be notified of the same.

II understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. This authorization, unless revoked, expires one year from the Effective Date, as set forth below.